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| PERSONAL FINANCIAL
STATEMENT |
| CONFIDENTIAL |
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| PERSONAL
INFORMATION |
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Please Print or
Type |
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If joint
statement, complete the
following: |
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Name
(Applicant) |
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Name (
Co-Applicant) |
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Name |
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Date of
Birth |
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Social Security
Number |
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Date of
Birth |
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Social Security
Number |
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XX / XX /
XX |
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xxx - xx -
xxxx |
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Street
Address |
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Street
Address |
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1234 Main
Street |
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City, State, Zip
Code |
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City, State, Zip
Code |
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City, State
48900 |
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Home Phone
Number |
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Business Phone
Number |
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Home Phone
Number |
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Business Phone
Number |
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517-123-4567 |
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517-765-4321 |
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Present
Employer |
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Present
Employer |
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Eloquent Jewelry Design |
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Street
Address |
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Street
Address |
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1234 Main
Street |
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City, State, Zip
Code |
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City, State, Zip
Code |
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City, State
48900 |
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Position |
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No. of
Years |
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Position |
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No. of Years |
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Owner |
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25 |
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| FAMILY
INFORMATION |
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No. of
Children/Dpndnts |
Ages |
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Do you
have a will? |
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If yes, date of
will |
Name of
Personal
Representative |
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No |
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Do you have a
trust? |
If yes,
date of trust |
Name of
Trustee/Successor Trustee |
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No |
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| Cash
Income and Expenditures Statement For the Year
Ending: |
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12/31/2005 |
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| ANNUAL
INCOME |
AMOUNT ($) |
ANNUAL
EXPENDITURES |
AMOUNT
($) |
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Salary
(Applicant) |
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$ |
15,000.00 |
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Property
Taxes/Assessments |
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$ |
2,500.00
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Salary
(Co-Applicant) |
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Income, State,
and Other Taxes |
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5,900.00
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Bonuses &
Commissions |
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0.00 |
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Rental
Payments |
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0.00 |
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Dividend
Income |
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0.00 |
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Mortgage Payments
(Principal & Interest) |
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22,000.00
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Interest
Income |
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150.00 |
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Other Loan
Payments (Rental House) |
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5,000.00
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Rental
Income |
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700.00 |
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Contract Payments
(Car, Charge Card, Etc.) |
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10,000.00
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S-Corp
Withdrawls |
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5,000.00 |
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Partnership/Sub-S
Contributions (E, F) |
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50,000.00
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Other
Gains/Losses |
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Insurance
Payments |
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13,000.00
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Other Investment
Income |
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Alimony, Child
Support Maintenance |
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0.00 |
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Other Income
(List)* |
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Education
Expenses |
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0.00 |
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IRA
Withdrawals |
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185,000.00 |
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Other Living
Expenses |
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0.00 |
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Other
Expense |
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0.00 |
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TOTAL INCOME |
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$ |
205,850.00
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TOTAL
EXPENDITURES |
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$ |
108,400.00
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The undersigned need not disclose income
from alimony, child support or separate
maintenance payments if such income is not to be
considered as a source for repayment of the
financial accommodations. |
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Page 1 of 4 |
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