Financial Statement Form - Fowler State Bank

Loan Information

Type of Credit *
Individual Joint Information on separate financial statement

Applicant Information

Applicant Name *
Address *
Address #2
Business/Occupation *
Employer's Name *
Employer's Address *
Employer's Address #2
Length of Employment *
Home Phone *
Business Phone *
Date of Birth *
SS/Tax ID # *

Joint Applicant Information

Applicant Name *
Address *
Address #2
Business/Occupation *
Employer's Name *
Employer's Address *
Employer's Address #2
Length of Employment *
Home Phone *
Business Phone *
Date of Birth *
SS/Tax ID # *

Annual Income

Salary Bonuses & Commissions
Dividends & Interest
Rental & Lease Income (Net)
Other Income - Itemize
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 Person's Salary/Bonuses/Commissions
Other Income - Itemize
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

Estimate of Annual Expenses

Income Taxes
Other Taxes
Insurance Premiums
Mortgage Payments
Rent Payable
Other Expenses
Additional Expenses
Expense Description
Expense Amount
Expense Description
Expense Amount
Expense Description
Expense Amount

Schedules

A. Cash in Banks & Notes Due to Banks (List all Real Estate Loans in Schedule E)

See Attached Itemization

Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due to Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
Name of Bank	Type of Account	Type of Ownership	Amount on Deposit	Notes Due Banks	Collateral (if any)
		Cash On Hand

B. Life Insurance (List only those Policies that you own)

See Attached Itemization

Company	Face of Policy	Cash Surrender Value	Policy Loans (if any)	Other Loans Policy as Collateral	Beneficiary
Company	Face of Policy	Cash Surrender Value	Policy Loans (if any)	Other Loans Policy as Collateral	Beneficiary
Company	Face of Policy	Cash Surrender Value	Policy Loans (if any)	Other Loans Policy as Collateral	Beneficiary
Company	Face of Policy	Cash Surrender Value	Policy Loans (if any)	Other Loans Policy as Collateral	Beneficiary

C. Securities Owned (Including U.S. Gov't Bonds and all other Stocks & Bonds)

See Attached Itemization

Face Value-Bonds/No. Shares Stock	Description (indicate those Not Registered in Your Name)	Type of Ownership	Cost	Market Value U.S. Gov. Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged to Secured Loan
Face Value Bonds/No. Share Stock	Description	Type of Ownership	Cost	Market Value US Gov Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged
Face Value Bonds/No. Share Stock	Description	Type of Ownership	Cost	Market Value US Gov Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged
Face Value Bonds/No. Share Stock	Description	Type of Ownership	Cost	Market Value US Gov Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged
Face Value Bonds/No. Share Stock	Description	Type of Ownership	Cost	Market Value US Gov Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged
Face Value Bonds/No. Share Stock	Description	Type of Ownership	Cost	Market Value US Gov Sec.	Market Value Marketable Security	Market Value Not Readily Marketable	Amount Pledged

D. Notes & Accounts Receivable (Money Payable or Owed to You Individually-Indicate % of your Ownership)

See Attached Itemization

Maker/Debtor	%	When Due	Cost	Original Amount	Balance Due Current Accounts	Balance Due Over 90 Days	Bal. Due Notes Rel. & Friends	Security (If Any)
Maker/Debtor	Percentage	When Due	Cost	Original Amount	Balance Due Current Accounts	Balance Due Over 90 Days	Balance Due Notes	Security (if any)
Maker/Debtor	Percentage	When Due	Cost	Original Amount	Balance Due Current Accounts	Balance Due Over 90 Days	Balance Due Notes	Security (if any)
Maker/Debtor	Percentage	When Due	Cost	Original Amount	Balance Due Current Accounts	Balance Due Over 90 Days	Balance Due Notes	Security (if any)
Maker/Debtor	Percentage	When Due	Cost	Original Amount	Balance Due Current Accounts	Balance Due Over 90 Days	Balance Due Notes	Security (if any)

E. Real Estate Owned (Indicate % of your Ownership Interest)

See Attached Itemization

Title in Name Of	%	Description & Location	Date Acquired	Original Cost	Present Value of Real Estate	Amount of Ins. Carried	Bal. Due.	Payment	Maturity
Title in Name of	Percentage	Description & Location	Date Acquired	Original Cost	Present Value	Insurnace Amount	Balance Due	Payment	Maturity
Title in Name of	Percentage	Description & Location	Date Acquired	Original Cost	Present Value	Insurnace Amount	Balance Due	Payment	Maturity
Title in Name of	Percentage	Description & Location	Date Acquired	Original Cost	Present Value	Insurnace Amount	Balance Due	Payment	Maturity
Title in Name of	Percentage	Description & Location	Date Acquired	Original Cost	Present Value	Insurnace Amount	Balance Due	Payment	Maturity

F. Mortgages and Contracts Owned (Indicate % of your Ownership Interest)

See Attached Itemization

Cont.	Mtg.	%	Maker Name	Maker Address	Property Covered	Starting Date	Payment	Maturity	Balance Due
Cont.	Mtg	Percentage	Maker Name	Maker Address	Property Covered	Starting Date	Payment	Maturity	Balance Due
Cont.	Mtg	Percentage	Maker Name	Maker Address	Property Covered	Starting Date	Payment	Maturity	Balance Due
Cont.	Mtg	Percentage	Maker Name	Maker Address	Property Covered	Starting Date	Payment	Maturity	Balance Due

G. Personal Property (Indicate % of your Ownership Interest)

See Attached Itemization

Description	%	Date When New	Cost When New	Value Today	Balance Due	To Whom Payable
Description	Percentage	Date When New	Cost When New	Value Today	Balance Due	Personal Payable
Description	Percentage	Date When New	Cost When New	Value Today	Balance Due	Personal Payable
Description	Percentage	Date When New	Cost When New	Value Today	Balance Due	Personal Payable

H. Notes, Accounts, Bills & Contract Payable

See Attached Itemization

Payable To	Other Obligors (if any)	When Due	Notes Due to Rel. & Friends	Notes Due Others (Not Banks)	Accounts & Bills	Contracts Payable	Collateral (if any) Payable
Payable To	Other Obligors (if any)	Notes When Due	Nots Due to Rel	Notes Due to Others (Not Banks)	Accounts & Bills	Contracts Payable	Collateral (if any) Payable
Payable To	Other Obligors (if any)	Notes When Due	Nots Due to Rel	Notes Due to Others (Not Banks)	Accounts & Bills	Contracts Payable	Collateral (if any) Payable
Payable To	Other Obligors (if any)	Notes When Due	Nots Due to Rel	Notes Due to Others (Not Banks)	Accounts & Bills	Contracts Payable	Collateral (if any) Payable

General Information

Are any Assets pledged other than described on SCHEDULES?
Yes No
Are you a Defendant in any suits or legal actions?
Yes No
Income Tax Return filed through what date?
Have you ever been declared Bankrupt in the last 10 yrs?
Yes No
Are you a Partner or Officer in any other venture?
Yes No

Contingent Liabilities

As Endorser, Co-Maker, or Guarantor
Yes No
On Leases or Contracts
Yes No
Legal Claims
Yes No
Federal - State Income Taxes
Yes No
Other

Assets

Description	Value
Cash on Hand and in Banks (Sched A)
Cash Value of Life Insurance (Sched B)
U.S. Gov. Securities (Sched C)
Other Marketable Securities (Sched C)
Assets Other Description
Assets Other Description
Assets Other Description
Total Liquid Assets
Real Estate Owned (Sched E)
Mortgages & Contracts Owned (Sched F)
Notes & Accounts Receivable-current (Sched D)
Notes & Accounts Receivable-over 90 days (Sched D)
Other Securities-not readily marketable (Sched C)
Personal Property (Sched G)
IRA & Tax Deferred Accounts
Other Assets See Attached Itemization
Total Productive Assets
Total Assets

Liabilities

Description	Amount
Notes Due to Banks (Sched A)
Notes Due to Relatives & Friends (Sched H)
Notes Due to Others (Sched H)
Accounts and Bills Payable (Sched H)
Loans on Life Insurance Policies (Sched B)
Contract Accounts Payable (Sched H)
Cash Rent Payable
Other Liabilities Due within 1 year (itemize)
Liabilities Other Description
Liabilities Other Description
Liabilities Other Description
Total Short Term Liabilities
Real Estate Mortgages Payable (Sched E)
Liens & Assements Payable
Other Debts
Total Long Term Liabilities
Total Liabilities
Net Worth (Total Assets minus Total Liabilities)
Total Liabilities & Net Worth

Attachments

Accepted formats: .pages, .doc, .docx, or .pdf

File 1 File 2 File 3 File 4 File 5

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 representation 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 question 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 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, 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 statement above.

Applicant Signature *
Co-Applicant Signature *
Bank Representative