Spreadsheet: 09b4d278-05ad-4b8d-a36f-e3191b5a5b27
Sheet: Sheet1

Unnamed: 0 | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9
FMB Bank |  |  |  |  |  | 100 Veterans Memorial Parkway- Wright City, MO 63390     (636) 745-3339
FINANCIAL STATEMENT
INDIVIDUAL - If you are applying for an individual credit, and are relying on your own income or assets, and not on the income or assets of another person as the basis for repayment of the credit request, complete all sections except Joint Party Information.
JOINT - If you are applying for joint credit with another person, complete all sections.  If appropriate, the joint applicant may complete a separate JBW personal finanical statement form, and the two forms may be submitted for application together.
Applicant(s) Name and Address |  |  |  | Creditor's Name and Address |  | Type of Credit - Check The Appropriate Box
 |  |  |  |  |  |  |  |  | Initials
 |  |  |  |  |  |  |  |  | Initials
 |  |  |  |  |  | Relationship
Individual Information |  |  |  |  |  | Joint Party Information
Business or Occupation |  |  |  |  |  | Business or Occupation
Employers Name |  |  |  |  |  | Employers Name
Employers Address |  |  |  |  |  | Employers Address
Length of Employment |  |  |  |  |  | Length of Employment
Home Phone |  |  |  | Bus. Phone |  | Home Phone |  | Bus. Phone
Date of Birth |  |  |  | S.S/Taxpayer ID |  | Date of Birth |  | S.S/Taxpayer ID
ASSETS |  |  |  | Note: [NAME] first. See Below |  |  | LIABILITIES
Cash On Hand and In Banks |  |  |  | Sched. A | 0 | Notes Due to Banks |  | Sched. A | 0
Cash Value of Life Insurance |  |  |  | Sched. B | 0 | Notes Due to Relatives and Friends |  | Sched. H | 0
U.S. Gov. Securities |  |  |  | Sched. C | 0 | Notes Due to Others |  | Sched. H | 0
Other Marketable Securities |  |  |  | Sched. C | 0 | Accounts and Bills Payable |  | Sched. H | 0
 |  |  |  |  |  | Loans on Life Insurance Policies |  | Sched. B | 0
 |  |  |  |  |  | Contract Accounts Payable |  | Sched. H | 0
 |  |  |  |  |  | Cash Rent Payable
Total Liquid Assets |  |  |  |  | 0 | Other Liabilities Due within 1 Year - Itemize
Real Estate Owned |  |  |  | Sched. E | 0
Mortgages and Contracts Owned |  |  |  | Sched. F | 0
Notes and Accounts Receivable - current |  |  |  | Sched. D | 0
Notes and Accounts Receivable - over 90 days |  |  |  | Sched. D | 0 | Total Short Term Liabilities |  |  | 0
Notes Due From Relatives and Friends |  |  |  | Sched. D | 0 | Real Estate Mortgages Payable |  | Sched. E | 0
Other Securities - Not Readily Marketable |  |  |  | Sched. C | 0 | Liens and Assessments Payable
Personal Property |  |  |  | Sched. G | 0 | Other Debts - Itemize
IRA and Tax Deferred Accounts |  |  |  |  |  | Total Long Term Liabilities |  |  | 0
Other Assets - Itemize |  |  |  |  |  | Total Liabilities |  |  | 0
Total Productive Assets |  |  |  |  | 0 | Net Worth (Total Assets Minus Total Liabilities) |  |  | 0
Total Assets |  |  |  |  | 0 | Total Liabilities and Net Worth |  |  | 0
ANNUAL INCOME |  |  |  |  |  | ESTIMATE OF ANNUAL EXPENSES
Salary Bonuses and Commissions |  |  |  |  |  | Income Taxes
Dividends and Interest |  |  |  |  |  | Other Taxes
Rental and Lease Income (Net) |  |  |  |  |  | Insurance Premiums
Alimony, child support, or separate maintenance income need not be |  |  |  |  |  | Mortgage Payments
revealed if you do not wish to have it considered as a basis for repaying |  |  |  |  |  | Rent Payable
this obligation. |  |  |  |  |  | Other Expenses
Other Income - Itemize
Provide the following information only if [NAME] is checked above.
Other Person's Salary, Bonuses and Commissions
Alimony, child support, or separate maintenance income need not be
revealed if you do not wish to have it considered as a basis for repaying
this obligation.
Other Income of Other Person - Itemize
Total |  |  |  |  | 0 | Total |  |  | 0
GENERAL INFORMATION |  |  |  |  |  | CONTINGENT LIABILITIES
Are any assets pledged other than described on Schedules |  |  |  |  |  | As Endorser, Co-maker or Guarantor
Are You a Defendant in Any Suits or Legal Actions? |  |  |  |  |  | On Leases or Contracts
Income Tax Return Filed Through What Date? |  |  |  |  |  | Legal Claims
Have you ever been declared Bankrupt in the last 10 years? |  |  |  |  |  | Federal - State Income Taxes
Are you a Partner or Officer in any other Venture? |  |  |  |  |  | Other
SCHEDULES
A             Cash in banks and notes due to banks |  |  |  |  | (List all Real Estate Loans in Schedule E)
Name of Bank |  | Type of Account |  | Type of Ownership | On Deposit | Notes Due Banks | Collateral (if any) and Type of Ownership
 |  |  |  | Cash On Hand
 |  |  |  | Totals | 0 | 0
B             Life Insurance  (List only those Policies that you own)
Company |  | Face of Policy |  | Cash Surrender Value | Policy Loan From Insurance Co. | Other Loans Policy as Collateral | Beneficiary
 |  | Totals |  | 0 | 0
C             Securities Owned  (Including U.S. Gov't Bonds and all other Stocks and Bonds)
Face Value-Bonds |  | Description |  | Type of |  | Market Value | Market Value | MARKET VALUE | Amount Pledged
No. Of Shares Stock |  | Indicate those not |  | Ownership | COST | U.S. Gov. [NAME]. | [NAME]. | Not Readily | To Secure Loan
 |  | Registered in your name |  |  |  |  |  | Marketable
 |  |  |  |  | Totals | 0 | 0 | 0
D             Notes and Accounts Receivable  (Money Payable or Owed to You Individually-Indicate % of your Ownership intrest)
Maker/Debtor |  | % | When Due | Original Amount | [NAME] | [NAME] | Bal Due Notes | Security (if any)
 |  |  |  |  | Current Accounts | Over 90 Days | Rel. and Friends
 |  |  |  | Totals | 0 | 0 | 0
E             Real Estate Owned  (Indicate % of your Ownership interest)
Title in name Of | % | Description/Location | Date Acquired | Original Cost | Present Value | Amount of | Mortgage or Contract Payable
 |  |  |  |  | of Real Estate | Ins. Carried | [NAME] | Payment | Maturity
 |  |  |  | Total | 0 | Total | 0
F             Mortgages and Contracts Owned  (Indicate % of your Ownership interest)
Cont. | Mtg. | % | Maker |  | Property Covered | Starting Date | Payment | Maturity | Balance Due
 |  |  | Address | Name
 |  |  |  |  |  |  |  | Totals | 0
G             Personal Property  (Indicate % of your Ownership interest)
Description |  | % | Date When New | Cost When New |  | Value Today | Balance
 |  |  |  |  |  |  | Balance Due | To Whom Payable
 |  |  |  |  | Totals | 0
H             Notes
Payable To |  | Other Obligors (if any) |  | When Due | Notes Due To | Notes Due "Others" | Accounts | Contracts | Collateral (if any)
 |  |  |  |  | Rel. and Friends | (Not Banks) | and Bills | Payable | Payable
 |  |  |  | Totals | 0 | 0 | 0 | 0
This information and the information provided on all accompanying financial statements and schedules is provided for the purpose of obtaining credit for the Applicant(s) or for the purpose of Applicant(s) guaranteeing credit for others. Applicant(s) acknowledge that representations made in this Statement will be relied on by Creditor in its decision to grant such credit. This Statement is true and correct in every detail and accurately represents the financial condition of the Applicant(s) on the date given below. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the undersigned.  Applicant(s) will promptly notify Creditor of any subsequent changes which would affect the accuracy of this Statement. Creditor is further authorized to answer any questions about Creditor's credit experience with Applicant(s). Applicant(s) are aware that any knowing or willful false statements regarding  the value of the above property for the purposes of influencing the actions of Creditor can be a violation of Federal Law 18 U.S.C. sec. 1014 and may result in a fine or imprisonment or both.
In addition, each individual signing below authorizes the Creditor to check their individual credit account and employment history and have a credit reporting agency prepare a credit report on them.
The undersigned declares that he/she has read and understands the statements above.
Date Signed ________________________________________ |  |  |  | Signature _________________________________________________ |  |  | Signature ___________________________________________
 |  |  |  |  |  |  | Other Person (If Applicable)