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Personal Financial Statement

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To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask you for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

You may apply for an extension of credit individually or jointly with another applicant. This statement and any applicable supporting schedules may be completed jointly by co-applicants if their assets and liabilities can be meaningfully and fairly presented on a combined basis, otherwise separate statements and schedules must be provided. If you are applying for an unsecured individual loan, you do not need to complete any information concerning a co-applicant unless another person will be permitted to use the account or you wish the co-applicant's or other person's income to be relied upon as the basis for repayment. For the purpose of obtaining credit from time to time with the bank, the following statement and information are furnished as complete, true, and accurate statement of the financial condition of the undersigned on October 22nd, 2014

Will there be a co-applicant?
No Yes
Applicant Information:





Been at current address less than 5 years?
No Yes
Previous Address (if less than 5 years at present):
Own Rent






Why do we ask?

In order to properly verify your identity, federal law requires we ask for a government-issued identification number, such as your Social Security number. This information is used solely for identity verification. Your Social Security number will not be used for any other purpose.

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Marital Status:
Unmarried Married Separated

required information bold

Co-Applicant Information:





Been at current address less than 5 years?
No Yes
Previous Address (if less than 5 years at present):
Own Rent






/ /












Marital Status:
Unmarried Married Separated

required information bold

Assets











Liabilities









Applicant Annual Income




Co-Applicant Annual Income




Are you a Co-Maker, Endorser, or Guarantor for any debt of an individual, corporation or partnership?
Yes No
Are you a defendant in any suit or legal action?
Yes No
Do you have any outstanding letters of credit or surety bonds?
Yes No
Have you ever gone through bankruptcy or had a judgement against you?
Yes No
Are any of your tax obligations past due?
Yes No
Have you made a will?
Yes No
What would be your estimated tax liability if you were to sell your major assets?
Schedule 1 / Cash, Savings, Certificates and IRA Accounts
























Schedule 2 / Securities Owned








































Schedule 3 / Life Insurance
























Schedule 4 / Receivables Due to Me on Mortgages and Contracts I Own


















Schedule 5 / Real Estate Owned




































Schedule 6 / Profit Sharing and Pension















Schedule 7 / Installments, Credit Lines and Notes




















Schedule 8 / Credit Accounts, Bills Due, Alimony/Child Support, Day Care, etc.















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Why do we ask?

Because the security of your confidential information is our number one priority, we use increased measures to ensure that our site is completely safe. This simple test can reduce spam and other forms of electronic traffic that could slow down this site or cause a disruption in service.

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You certify that the information provided in this statement is true and correct. So long as you owe any sums to the bank, you agree to give the bank prompt written notice of any material change in your financial condition and upon request, you agree to provide the bank with an updated personal financial statement. The bank is authorized to retain this personal financial statement whether or not credit is approved and is further authorized to verify your credit and employment history or any other information in this statement. This application does not obligate the bank to make any loan even if you meet the normal standards the bank considers in determining whether to approve or deny the application.