Personal Financial Statement

Personal Financial Statement Page 1

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Applicant Information

First Name *
Middle Initial
Last Name *
Your Email Address *
Residence Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Residential Phone *
Business Phone *
Date of Birth *
Social Security Number *
Driver's License/ID Number *
State Issued *
Date Issued *
Expiration Date *
Employer Name *
Number of Years *
Position or Occupation *
Nearest relative not living with me. *
Relationship *
Phone *
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Co-Applicant Information (When Completed and signed denotes intent to apply for credit)

First Name
Middle Initial
Last Name
Residential Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date of Birth
Social Security Number
Driver's License/ID Number *
State Issued
Date Issued
Expiration Date
Residential Phone
Business Phone
Employer Name
Position or Occupation
Number Of Years
Nearest relative not living with me
Relationship
Phone
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Statement of Financial Condition

Assets (omit cents)

$ Cash on hand & in Banks
$ Savings Accounts
$ IRA or Other Retirement Account
$ Life Insurance-Cash Surrender Value Only (Complete Section 8)
$ Stocks and Bonds (Describe in Section 3)
$ Real Estate (Describe in Section 4)
$ Automobile-Present Value
$ Other Personal Property (Describe in Section 5)
$ Other Assets (Describe in Section 5)
TOTAL Total Dollar Amount of Assets

LIABILITIES (omit cents)

$ Accounts Payable
$ Notes Payable to Banks and Others (Describe in Section 2)
$ Installment Account (Auto)
$ Mo. Payments
$ Installment Account (Other)
$ Mo. Payments
$ Loan on Life Insurance
$ Mortgages on Real Estate (Describe in Section 4)
$ Unpaid Taxes (Describe in Section 6)
$ Other Liabilities (Describe in Section 7)
TOTAL LIABILITIES
NET WORTH
TOTAL LIABILITIES AND NET WORTH

Section 1

Source of Income

$ Salary
$ Net Investment Income
$ Real Estate Income
$ Other Income (Describe below)*
Description of Other Income in Section 1.
*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

Contingent Liabilities

$ As Endorser or Co-Maker
$ Legal Claims & Judgments
$ Provision for Federal Income Tax
$ Other Special Debt

Section 2. Notes Payable to Banks and Others.

(Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Noteholder #1

Name and Address of Noteholder(s)
How Secured or Endorsed /Type of Collateral
$ Original Balance
$ Current Balance
$ Payment Amount
Payment Frequency (monthly, etc)

Noteholder #2

Name and Address of Noteholder(s)
How Secured or Endorsed /Type of Collateral
$ Original Balance
$ Current Balance
$ Payment Amount
Payment Frequency (monthly, etc)

Noteholder #3

Name and Address of Noteholder(s)
How Secured or Endorsed /Type of Collateral
$ Original Balance
$ Current Balance
$ Payment Amount
Payment Frequency (monthly, etc)

If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)

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Personal Financial Statement Page 2

Section 3- Stocks and Bonds

Securities #1

Name of Securities
Number of Shares
$ Cost
$ Market Value/Quotation/Exchange
Date of Quotation/Exchange
$ Total Value

Securities #2

Name of Securities
Number of Shares
$ Cost
$Market Value/Quotation/Exchange
Date of Quotation/Exchange
$ Total Value

Securities #2

Name of Securities
Number of Shares
$ Cost
$ Market Value/Quotation/Exchange
Date of Quotation/Exchange
$ Total Value

If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)

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Section 4. Real Estate Owned

Property A

Type of Property
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage

Property B

Type of Property
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage

Property C

Type of Property
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Date Purchased
Original Cost
Present Market Value
Name & Address of Mortgage Holder
Mortgage Account Number
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage

If you have additional attachments, please upload here. Each attachment must be identified as a part of this statement and signed.)

File Upload Upload Additional Attachments
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File Upload Upload Additional Attachments

Section 5. Other Personal Property and Other Assets

(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 6. Unpaid Taxes

(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities.

(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 8. Life Insurance Held.

(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)
Authorization I authorize Barthelemy Commercial Capital/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These statements are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18 U.S.C. 1001).
Electronic Signature *Type Name
Date *
Social Security Number *
Email *
Co-Applicant Electronic Signature (If applicable) Type Name
Date
Co-Applicant Social Security Number (if applicable)
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