Documentos de Académico
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DATE OF STATEMENT
Individual Credit
Joint Credit
If Joint Credit, initial here: ______ ______
NAME OF INDIVIDUAL:
HOME ADDRESS
HOME PHONE
DATE OF BIRTH
TOTAL LIABILITIES
NET WORTH
Other Income
TOTAL
No
Yes
Amount $
CONTINGENT LIABILITIES
NATURE OF LIABILITY
Liabilities as Endorser, Co-Maker or Guarantor
Liabilities on Leases and Contracts
Liabilities on Letters of Credit
Contested Tax Liens
Involvement in Pending Legal Actions, Claims, Judgments, etc.
Form 07 0721 1
DESCRIPTION
AMOUNT
Page One
SCHEDULE A:
SCHEDULE B:
ORIGINAL AMOUNT
ACCOUNT NUMBER
CURRENT BALANCE
BALANCE OWING
SCHEDULE C:
ISSUING COMPANY
TYPE OF ACCOUNT
PAYMENT SCHEDULE
COLLATERAL
MATURITY
NO. OF SHARES
OR FACE AMT.
OF BONDS*
VALUE
Per Share
Total
IF PLEDGED, TO WHOM?
WHERE TRADED?
SCHEDULE D:
PERCENT OWNERSHIP
ORIGINAL COST
PRESENT VALUE
IF PLEDGED, TO WHOM?
Page Two
LIFE INSURANCE
SCHEDULE E:
POLICY
NUMBER
INSURANCE COMPANY
POLICY OWNER
SCHEDULE F:
PARCEL
NUMBER
BENEFICIARY
TYPE OF POLICY
YEAR
ACQUIRED
COST
FACE AMOUNT
CASH VALUE
Homestead)
IndicatesAPPRAISAL
By Whom
Date
Amount
LOANS
AGAINST
POLICY
NAME OF
TITLE HOLDER
1.
2.
3.
4.
5.
PARCEL
NUMBER
MORTGAGE OR
OTHER LIEN
ORIGINAL
AMOUNT
PAYABLE TO:
INTEREST
RATE
AMOUNT PAYABLE
PER MONTH
AMOUNT OF
INSURANCE
1st
1.
2nd
1st
2.
2nd
1st
3.
2nd
1st
4.
2nd
1st
5.
2nd
SCHEDULE G:
LEGAL DESCRIPTION
WI
OR RI
NET REVENUE
INTEREST
SCHEDULE H:
VESTED PENSIONS, RETIREMENT FUNDS, IRA, KEOUGH
DESCRIPTION
Form 07 0721 1
PRESENT
BALANCE
AMOUNT
MONTHLY
INCOME
MONTHLY
EXPENSE
PRESENT VALUE
PURCHASER
OF PRODUCT
SCHEDULE I:
OTHER PERSONAL ASSETS
DESCRIPTION
AMOUNT
Page Three
SCHEDULE J:
DUE TO WHOM
SCHEDULE K:
AMOUNT
HOW PAYABLE
MATURITY
COLLATERAL PLEDGED
DESCRIPTION
AMOUNTS
AMOUNTS
TOTAL
BUSINESSES IN WHICH UNDERSIGNED IS A PRINCIPAL OR PARTNER
SCHEDULE L:
TYPE OF BUSINESS
% OWNERSHIP
Yes
POSITION/TITLE
No
Has Undersigned made an assignment for benefit of creditors or been involved in bankruptcy proceedings during the past ten years?
Yes
No
Separated
Number of Dependents
POSITION/TITLE
YEARS EMPLOYED
SIGNATURES
This Financial Statement, supporting schedules and information are submitted by the Undersigned to the herein named Financial Institution for the
purpose of establishing, obtaining, or maintaining credit. It is a true, complete, and correct representation of the Undersigned's financial condition as
of the date shown above. The Financial Institution is authorized by the Undersigned to check credit and employment history, to verify the accuracy of
the information contained herein, and to answer questions about its credit experience with the Undersigned.
SIGNATURE
DATE SIGNED
WITNESS
SIGNATURE
DATE SIGNED
WITNESS
Page Four