PERSONAL FINANCIALSTATEMENT

StatementDate:

PersonalInformation

Name: / SSN:
Address: / Birthdate:
City, StateZip: / Dependents:
HomeTelephone: / BusinessTelephone:

SectionI

ASSETS / LIABILITIES
1Cash on Hand & inBanks
2Cash Value of LifeInsurance3 U.S. Gov.Securities
4Other MarketableSecurities
5Notes & Accounts Receivable -Good
6Other Assets Readily Convertible to Cash -Itemize
7 / 21Notes Due toBanks
22Notes Due to Relatives &Friends23 Notes Due toOthers
24Accounts & BillsPayable
25Unpaid Income Taxes Due - FederalState26 Other Unpaid Taxes &Interest
27 LoansonLifeInsurancePolicies28 Contract AccountsPayable
29Cash Rent Owed
30Other Liabilities Due within 1 Year -Itemiz31
32
33TOTAL CURRENTLIABILITIES$0.0034 Real Estate MortgagePayable
35LiensAssessmentsPayable36 Other Debts -Itemize
37
38TOTALLIABILITIES$0.00
39Net Worth (Total Assets - Total Liabilities)$0.00
40TOTAL LIABILITIES & NET WORTH$0.00
8
9
10TOTAL CURRENTASSETS / $0.00

$0.00
11 Real EstateOwned
12 Mortgages & ContractsOwned
13 Notes & Accounts Receivable -Doubtful
14 Notes Due from Relatives &Friends
15 Other Securities - Not ReadilyMarketable
16 PersonalProperty
17 Other Assets -Itemize
18
19
20TOTAL ASSETS
ANNUALINCOME / ESTIMATE OF ANNUAL EXPENSES
Salary, Bonuses &Commissions / IncomeTaxes
Dividends &Interest / OtherTaxes
Rental & Lease Income(Net) / InsurancePremiums
Other Income -Itemize / MortgagePayments
Other Persons Salary, Bonuses & Commissions / RentPayable
Other Income of Other Person -Itemize / OtherExpenses
Total / $0.00 / Total / $0.00
GENERALINFORMATION / CONTINGENTLIABILITIES
Are any AssetsPledged? / No / Yes / AsEndorser,Co-makerorGuarantor-YesOn Leases orContracts
LegalClaims
Federal-StateIncomeTaxesOther-
Are you a Defendant in any Suits or Legal Actions?NoYes(Explain)
HaveyoueverbeendeclaredBankruptinthelast10years?NoYes(Explain)

A CASH IN BANKS AND NOTES DUE TO BANKS

SectionII

Name ofBank / Type ofAccount / Type ofOwnership / OnDeposit / Notes DueBanks / COLLATERAL (Ifany)
& Type ofOwnership
Cash onHand
TOTALS
$0.00 / $0.00

SECTION II (Continued)

B LIFE INSURANCE (List only those Policies that youown)

TOTALS

CSECURITIES OWNED

TOTALS

DNOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually-Indicate by a X if Others have an OwnershipInterest)

TOTALS

EREAL ESTATE OWNED (Indicate by a X if Others have an OwnershipInterest)

TOTAL

F MORTGAGES AND CONTRACTS OWNED (Indicate by a if Others have an OwnershipInterest)

TOTALS

G PERSONAL PROPERTY (Indicate by a X if Others have an OwnershipInterest)

TOTAL

H NOTES (Other than Bank, Mortgage and Insurance CompanyLoans)

TOTALS

Forthepurposeofprocuringcreditfromtimetotime,I/Wefurnishtheforegoingasatrueandaccuratestatementofmy/ourfinancialcondition.AuthorizationisherebygiventotheLendertoverifyinanymanneritdeemsappropriateanyandallitemsindicatedonthisstatement.TheundersignedalsoagreestonotifytheLenderimmediatelyinwritingofanysignificantadversechangeinsuchfinancialcondition.

Signature:Signature:Date: