CONFIDENTIAL

PERSONAL FINANCIAL STATEMENT

Statement Date:

Personal Information

Name: SSN:
Address: Birthdate:
City, State Zip: Dependents:
Home Telephone: Business Telephone:

Section I
ASSETS LIABILITIES
1 Cash on Hand & in Banks $8947.00 21 Notes Due to Banks $4095.00
2 Cash Value of Life Insurance $12030.00 22 Notes Due to Relatives & Friends $697.00
3 U.S. Gov. Securities $3494.00 23 Notes Due to Others $359.00
4 Other Marketable Securities $4553.00 24 Accounts & Bills Payable $569.00
5 Notes & Accounts Receivable – Good $14957.00 25 Unpaid Income Taxes Due - Federal State $420.00
6 Other Assets Readily Convertible to Cash – Itemize $2248.00 26 Other Unpaid Taxes & Interest $134.00
7 27 Loans on Life Insurance Policies $1283.00
8 28 Contract Accounts Payable $935.00
9 29 Cash Rent Owed $1346.00
10 TOTAL CURRENT ASSETS $46229.00 30 Other Liabilities Due within 1 Year - Itemiz $108.00
11 Real Estate Owned $22000.00 31
12 Mortgages & Contracts Owned $10384.00 32
13 Notes & Accounts Receivable – Doubtful $5537.00 33 TOTAL CURRENT LIABILITIES $9946.00
14 Notes Due from Relatives & Friends $1027.00 34 Real Estate Mortgage Payable $3500.00
15 Other Securities - Not Readily Marketable $2304.00 35 Liens & Assessments Payable $2390.00
16 Personal Property $98450.00 36 Other Debts - Itemize $1458.00
17 Other Assets – Itemize $9068.00 37
18 38 TOTAL LIABILITIES $17294.00
19 39 Net Worth (Total Assets - Total Liabilities) $177705.00
20 TOTAL ASSETS $194999.00 40 TOTAL LIABILITIES & NET WORTH $194999.00

ANNUAL INCOME ESTIMATE OF ANNUAL EXPENSES

Salary, Bonuses & Commissions $89900.00 Income Taxes $7750.00
Dividends & Interest $13020.00 Other Taxes $5650.00
Rental & Lease Income (Net) $9800.00 Insurance Premiums $5495.00
Other Income - Itemize $7870.00 Mortgage Payments $4656.00
Other Persons Salary, Bonuses & Commissions $0.00 Rent Payable $6733.00
Other Income of Other Person - Itemize $0.00 Other Expenses $2800.00
Total $120590.00 Total $33084.00

GENERAL INFORMATION CONTINGENT LIABILITIES

Are any Assets Pledged? No Yes As Endorser, Co-maker or Guarantor- Yes
Are you a Defendant in any Suits or Legal Actions? No Yes On Leases or Contracts
(Explain) Legal Claims
Have you ever been declared Bankrupt in the last 10 years? No Yes Federal - State Income Taxes
(Explain) Other -

Section II
A CASH IN BANKS AND NOTES DUE TO BANKS
COLLATERAL (If any)
Name of Bank Type of Account Type of Ownership On Deposit Notes Due Banks & Type of Ownership

Cash on Hand
TOTALS $0.00 $0.00

PERSONAL FINANCIAL STATEMENT 1

 CONFIDENTIAL

SECTION II (Continued)
B LIFE INSURANCE (List only those Policies that you own)

Cash Surrender Policy Loan from Other Loans Policy

Company Face of Policy Value Insurance Co. as Collateral BENEFICIARY

TOTALS $0.00 $0.00

C SECURITIES OWNED
Face Value-Bonds Indicate those Not Market Value U.S. Market Value MARKET VALUE Not Readily Marketable
No. of Shares Stock Registered in Your Type of Ownership COST Gov. Sec. Marketable Sec. SECURITIES Amount Pledged to Secured Loans

TOTALS $0.00 $0.00 $0.00

D NOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually-Indicate by a X if Others have an Ownership Interest)
Balance Due Good Balance Due Bal. Due Notes Rel. &
MAKER/DEBTOR X When Due Original Amount Accounts Doubtful Accounts Friends Security (if any)

TOTALS $0.00 $0.00 $0.00

E REAL ESTATE OWNED (Indicate by a X if Others have an Ownership Interest) MORTGAGE OR CONTRACT PAYABLE
TITLE IN NAME Description & Present Value of Real Amount of Ins.
OF Location X Date Acquired Original Cost Estate Carried Bal. Due Payment Maturity To Whom Payable

TOTAL $0.00 TOTAL $0.00

F MORTGAGES AND CONTRACTS OWNED (Indicate by a if Others have an Ownership Interest)

Contract Mortgage X Maker Name Maker Address Property Covered Start Date Payment Maturity Balance Due

TOTALS $0.00

G PERSONAL PROPERTY (Indicate by a X if Others have an Ownership Interest)

DESCRIPTION X Date When New Cost When New Value Today Balance Due To Whom Payable

TOTAL $0.00

H NOTES (Other than Bank, Mortgage and Insurance Company Loans)

Other Obligors (if Notes Due To Rel. & Notes Due 'Others' Accounts & Bills
PAYABLE TO any) When Due Friends (Not Banks) Payable Contracts Payable COLLATERAL (if any)

TOTALS $0.00 $0.00 $0.00 $0.00

For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition.
Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also
agrees to notify the Lender immediately in writing of any significant adverse change in such financial condition.

Signature: Signature: Date:

PERSONAL FINANCIAL STATEMENT 1