Blank Bank Statement

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CONFIDENTIAL PERSONAL FINANCIAL STATEMENT Statement Date: Personal Information Name: Address: City, State Zip: Home Telephone: SSN: Birthdate: Dependents: Business Telephone: Section I ASSETS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Cash on Hand in Banks Cash Value of Life Insurance U.S. Gov. Securities Other Marketable Securities Notes Accounts Receivable - Good Other Assets Readily Convertible to Cash - Itemize TOTAL CURRENT ASSETS Real Estate Owned Mortgages Contracts Owned Notes Accounts Receivable - Doubtful Notes Due from Relatives Friends Other Securities - Not Readily Marketable Personal Property Other Assets - Itemize 0.00 TOTAL ASSETS 0.00 ANNUAL INCOME Salary, Bonuses Commissions Dividends Interest Rental Lease Income (Net) Other Income - Itemize Other Persons Salary, Bonuses Commissions Other Income of Other Person - Itemize Total 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 LIABILITIES Notes Due to Banks Notes Due to Relatives Friends Notes Due to Others Accounts Bills Payable Unpaid Income Taxes Due - Federal State Other Unpaid Taxes Interest Loans on Life Insurance Policies Contract Accounts Payable Cash Rent Owed Other Liabilities Due within 1 Year - Itemize TOTAL CURRENT LIABILITIES Real Estate Mortgage Payable Liens Assessments Payable Other Debts - Itemize 0.00 TOTAL LIABILITIES Net Worth (Total Assets - Total Liabilities) TOTAL LIABILITIES NET WORTH 0.00 0.00 0.00 ESTIMATE OF ANNUAL EXPENSES Income Taxes Other Taxes Insurance Premiums Mortgage Payments Rent Payable Other Expenses 0.00 Total GENERAL INFORMATION Are any Assets Pledged No Yes Are you a Defendant in any Suits or Legal Actions (Explain) No No Have you ever been declared Bankrupt in the last 10 years (Explain) 0.00 CONTINGENT LIABILITIES As Endorser, Co-maker or Guarantor- Yes Yes On Leases or Contracts Legal Claims Yes Federal - State Income Taxes Other - Section II A CASH IN BANKS AND NOTES DUE TO BANKS Name of Bank Type of Account Type of Ownership Cash on

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