Name

Co-Applicant Name

Address

Address

City, State, Zip Code

City, State, Zip Code

Date of Birth

Date of Birth

SS #

SS #

Home Phone

Home Phone

Business Phone

Business Phone

Employer

Employer

Address

Address

City, State, Zip Code

City, State, Zip Code

How Long

How Long

Job Title

Job Title

ASSETS

LIABILITIES

Cash on Hand

Accounts Payable

Savings Accounts

Notes Payable to Banks and Others (describe in section 5 )

Retirement Accounts

Loan on Life Insurance

Stocks and Bonds (describe in section 1)

Liens on Real Estate (describe in section 2)

Real Estate (describe in section 2)

Tax liabilities

Personal Property

Other Liabilities (describe in section 6)

Investment in Business (describe in section 3)

Cash Value Life Insurance (describe in section 4)

Total Liabilities

Total Assets

Net Worth

ANNUAL SOURCES of INCOME

ANNUAL SOURCES of INCOME (Co-Applicant)

Salary

Salary

Investment Income

Investment Income

Real Estate Income

Real Estate Income

Social Security Income

Social Security Income

Other (describe below)*

Other (describe below)*

Description of Other Income :      

*Alimony or child support payments need not be disclosed in “Other” unless it is desired to have such payments counted toward total income.

Description of Other Income :      

* Alimony or child support payments need not be disclosed in “Other” unless it is desired to have such payments counted toward total income.

OTHER INFORMATION

OTHER INFORMATION (Co-Applicant)

Are you an endorser or co-maker on any Notes?      

Are you an endorser or co-maker on any Notes?      

Are you a defendant in any legal action?      

Are you a defendant in any legal action?      

Have you ever filed Bankruptcy?      

Have you ever filed Bankruptcy?      

If yes to any of the above, please explain:      

If yes to any of the above, please explain:      

Section 1. Stocks and Bonds (Use attachments if necessary)

Number of Shares

Name of Security

Market Value

Date of Market Value

Total Value

Section 2. Real Estate Owned

Address

% Owned

Market Value

Outstanding Liens

Lienholder

Monthly Payment

Section 3. Investments in Business Ventures

Business Name

Position/Title

% Ownership

Business Net Worth

Current Market Value

Line of Business

Section 4. Cash Value of Life Insurance

Life Insurance Company

Policy Owner

Beneficiary/Relationship

Face Amount

Loans

Current Cash Value

Section 5. Notes Payable to Banks and Others

Lender

Origination Date

Balance

Monthly Payment

Collateral

Term

Section 6. Other Liabilities (Please describe in detail)