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<br />~ OMS Approval No. 3245-0188 <br />. Exp. Date: 10.31-89 <br />. PERSONAl. FINANCIAL STATEMENT <br />. . ,:t <br />""'taT\.-":"" As of 19_ <br />Complete this lonn i11) _ sola proprietorship by lha proprietor; 2) _ partnership by each partnar: 3) _ corporation by each olfocer and <br />each stockholder with 2O'Ml or mora ownership: 4) any other person or _ntlty providing _ guaranty on lhe,loan. <br />Name Residence Phone <br />Residence Address . <br />CIIv. State & Zio <br />Business Name 01 Applicanl/Borrower <br />ASSETS LIABILITIES <br /> (Omn Cents) (Omn Cents) <br />Cash on hand & in Banks..................$ Accounts Payable .. . .. .. . . .. . .. .. .. . .. . ..$ <br />Savings Accounts......................... Notes Payable (to Bk & Othars <br />IRA..................................... . (Describe in Section 2). .. .. . .. . .. .. . .. .. <br />Accounts & Notes Receivable Installment Account (Auto) <br />(Describe in Section 6) .................. Mo. Payments $ <br />Lne Insurance--Cash Installment Account (Other) <br />Surrender Value Only ................... Mo. Payments $ <br />Stocks and Bonds Loans on Lile Insurance .................. <br />(Describe in Section 3) .................. Mortgages on Real Estate.. .. . .. .. .. . .. . . . <br />Real Estate (Describe in Section 4). . . . . . .. .. . . .. .. .. <br />(Describe in Section 4) .................. Unpaid Taxes <br />Automobile-Present Value. . . . . . . . . . . . . . . . (Describe in Section 7). .. .. .. .. .. .. .. . . . <br />Other Personal Property. . . . . . . . . .. .. . .. .. . Other Uabilities <br />(Describe in Section 5) (Describe in Section 8). . .. .. .. .. . .. .. . .. <br />Other Assets......................... .... <br />(Describe in Section 6) .................. Total Liabilities........................... <br /> Net Worth...................... ......... <br />Total. . . . . . . . . . . . .. . . . . . . .. . . . ..$ Total. . . . .. . .. . . . . . . . . . . . .. . . . . . .$ <br />Section 1. Source 01 Income Contingent Uabilities <br />Salary ............................ $ As Endorser or Co-Maker .............................$ <br />Net Investment Income. . . . . . . . . . . . . Legal Claims & Judgments. . . . .. . . . . . . .. . . . . . . . . . .. . . . <br />Real Estate Income. . . . . . . . .. .. .. .. Provision lor Fed Income Tax.......................... <br />Other Income (Describe)" . . . . . . . . . . . Other Special Debt....... ............................ <br />Description 01 Items Listed in Section I <br />"(Alimony or child support payments need not be disclosed in "Other Income unless it is desired to have such payments counted <br />toward total income,) <br />section 2. Notes Payable to Banks and-ofhers <br />Name & Address 01 Original Currant Payment Tarms How Secured or <br />Noteholder Balance Balance Amount (Monthly-etc.) Endorsed-Type 01 Collateral <br />SBA Form 413 (10-87) Use 10-86 edition until exhausted ReIer to SOP 50 10 <br /> (Response Is required to Obtain _ benefit) <br /> <br />32 <br />