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Loan Information

  • Type of Credit *

Applicant Information

Joint Applicant Information

Annual Income

  • 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
  • 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

  • Additional Expenses


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

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

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

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)

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

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

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

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

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

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

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

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

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

H. Notes, Accounts, Bills & Contract Payable

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

General Information

  • Are any Assets pledged other than described on SCHEDULES?
  • Are you a Defendant in any suits or legal actions?
  • Have you ever been declared Bankrupt in the last 10 yrs?
  • Are you a Partner or Officer in any other venture?

Contingent Liabilities

  • As Endorser, Co-Maker, or Guarantor
  • On Leases or Contracts
  • Legal Claims
  • Federal - State Income Taxes


Description Value


Description Amount


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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.