Personal Financial Statement

Personal Financial Statement

Name
Address
Social Security No / Date of Birth
Cell Phone / Work Phone / Email
Present Employer / Position
Address of
Employer
I am the sole proprietor owner or controlling shareholder of the business
Business Website:

APPLICANT’S MARITAL STATUS: Married Unmarried Separated

In connection with this Personal Financial Statement, I am applying for a loan / line of
$ / , for the purpose of
in my name alone
jointly with my spouse, whose name is
jointly with another person whose Personal Financial Statement is attached
Spousal Information: / Social Security No: / Date of Birth:
Employer
Address of Employer
Position / Business Phone
DATE OF VALUATIONS / List all amounts in dollars. Omit cents
Please attach a separate sheet if you need more space to complete a detail schedule
ASSETS / LIABILITIES
Cash in / $ / Accounts Payable / $
Cash in Other Banks (Detail) Provide Verifications i.e. Bank Statements / $ / $
$ / Notes payable to Bank of Marin / $
$ / $
$ / Notes Payable to Others (Schedule 7) / $
Accounts Receivable / $ / Income Taxes Payable / $
$ / $
Notes Receivable (Schedule 1) / $ / Other Taxes Payable / $
Mortgages & Deeds of Trust Owned (Sch 2) / $ / Delinquent Property Taxes / $
Securities Owned (Schedule 3) / $ / $
Retirement Accounts (Schedule 3) / $ / Loans on Life Insurance (Schedule 4) / $
Cash Surrender Value of Life Insurance. (Schedule 4) / $ / Mortgages or Liens on Real Estate (Schedule 6) / $
Real Estate (Schedule 5) / $ / Installment Contracts Payable / $
Automobiles / $ / $
$ / $
Personal Property / $ / Other Liabilities / $
$ / Credit Cards / $
Other Assets (Detail) / $ / $
$ / $
$ / TOTAL LIABILITES / $
$ / NET WORTH / $
TOTAL / $ / TOTAL / $
ANNUAL INCOME / ANNUAL EXPENDITURES / CONTINGENT LIABILITIES
Employment Income / $ / Mortgage Payments &Interest / $ / As Endorser / $
$ / Other Loan Payments / $ / As Guarantor / $
Dividends / $ / Property Taxes / Assessments / $ / Damage Claims / $
Interest / $ / Income and Other Taxes / $ / For Taxes (past years) / $
Rentals / $ / Insurance / $ / Other (Detail) / $
Alimony, Child support or maintenance * / $ / Alimony, child support / maintenance payments* / $ / $
Other / $ / Living Expenses / $ / $
RE Commissions / $ / Other / $ / $
$ / $ / $
$ / $ / $
$ / $ / $
$ / $ / Check here if “None”
TOTAL
INCOME / $ / TOTAL
EXPENDITURES / $ / TOTAL CONTINGENT LIABILITIES / $
*you need not show this unless you wish to consider it

SCHEDULE 1 Notes Receivable

NAME OF DEBTOR / COLLATERAL / PAYABLE / MATURITY DATE / TOTAL AMOUNT DUE
$ / Per / $
$ / Per / $
TOTAL / $

SCHEDULE 2 Mortgages and Deeds of Trust Owned

NAME OF DEBTOR / TYPE OF PROPERTY / 1ST OR
2ND LEIN / VALUE OF PROPETY / HOW PAYABLE / UNPAID BALANCE
$ / $ / Per / $
$ / $ / Per / $
$ / $ / Per / $
$ / $ / Per / $
$ / $ / Per / $
TOTAL / $
NO. SHARES
OR BOND
AMOUNT / DESCRIPTION / TITLE IN NAME OF / HOW
HELD
CODE « / PRESENT
MARKET
VALUE / L=Listed
U=Unlisted
R=Retirement
$
$
$
$
$
TOTAL / $

SCHEDULE 4 Life Insurance

INSURED / FACE AMOUNT
OF POLICY / INSURANCE
COMPANY / BENEFICIARY / CASH VALUE / LOANS
$ / $ / $
$ / $ / $
$ / $ / $
TOTAL / $ / $

SCHEDULE 5 Real Estate

ADDRESS AND TYPE OF PROPERTY / TITLE IN NAME OF / HOW HELD
CODE « / MONTHLY INCOME / COST YEAR ACQUIRED / PRESENT MARKET
VALUE / TOTAL BALANCE
OWED (DETAL
IN SCHEDULE 6)
$ / $ / $ / $
Year
$ / $ / $ / $
Year
$ / $ / $ / $
Year
$ / $ / $ / $
Year
TOTAL / $ / $

SCHEDULE 6 Mortgages or Liens on Real Estate

TO WHOM PAYABLE / INDICATE 1ST OR 2ND MORTGATE / HOW PAYABLE / INTEREST RATE / MATURITY DATE / BALANCE OWING
SEE ATTACHED / $ / Per / $
$ / Per / $
$ / Per / $

SCHEDULE 7 Notes Payable

TO WHOM / ADDRESS / COLLAERAL / INTEREST RATE / UNPAID BALANCE
$
$
$
«
HOW HELD / COMMUNITY PROPERTY / SEPARATE PROPERTY (indicate applicable abbreviation)
CODES / ALWAYS INDICATE “CP” / “SO” = SINGLE OWNERSHIP / “JT” = JOINT TENANTS / “TIC” = TENANTS IN COMMON
Have you any contingent liabilities and/or have you guaranteed or co-signed any other loans not shown on this statement / Yes No
Have you ever gone through bankruptcy or had a judgment against you? / Yes No
Are any assets pledged or debts secured except as shown? / Yes No
Have you made a will? / Yes No
Are your tax returns being audited by the I.R.S.? / Yes No
Are any assets held in trust? / Yes No
If yes, what is the name of the trust?
Is the Trust Revocable? / Yes No

I have attached the following items to support my application

Current Balance Sheet for my Business
Profit & Loss Statement(s) for my Business for 20, 20, 20, and year to date for 20 .
Copy of personal or business checking account statement(s)
Copy of personal or business bank account statement(s)
Current stock/IRA/bond statement(s)

YOUR REPRESENTATIONS AND WARRANTIES

I understand that the HL Property Management, Landlord, Landlord’s agent, or property owner is relying on the information in this financial statement (including the designation of my property as separate or community property) in deciding to extend credit, approve a new lease or assumption of an existing lease, I have requested. I promise that this is a true statement of my financial condition as of the date of valuations. You may rely on it as being true and correct until I otherwise notify you in writing. You may retain and verify this statement and may seek credit information about me, by obtaining a consumer credit report or otherwise. If this is a joint financial statement, these representations and warranties are from each of us.

I HAVE READ, UNDERSTAND AND AGREE TO MAKE THESE REPRESENTATIONS AND WARRANTIES.

Date / Your Signature
Date / Your Spouse’s Signature (if you are requesting the financial accommodation jointly)