PERSONAL FINANCIAL STATEMENT
For the purpose of procuring and maintaining credit from time to time in any form whatsoever with the above named firm or its designee (and any assignee or potential assignee thereof), for claims and demands against the undersigned, the undersigned submits the following as being a true and accurate statement of my financial condition on the following date, and agree that if any change occurs that materially reduces the means or ability of the undersigned to pay all claims or demands against it. the undersigned will immediately and without delay notify the said firm and unless the firm is so notified it may continue to rely upon the statement herein given as a true and accurate statement of the financial condition of the undersigned as of the close of business.

SECTION 1 - INDIVIDUAL INFORMATION (Type or Print)	SECTION 2 - OTHER PARTY INFORMATION  (Type or Print)	
Name	Name	
Residence Address	Residence Address	
City, State & Zip	City, State & Zip	
Position & Occupation	Position & Occupation	
Business Name	Business Name	
City, State & Zip	City, State & Zip	
Res. Phone                          Bus. Phone	Res. Phone                         Bus. Phone	

SECTION 3 - STATEMENT OF FINANCIAL CONDITION AS OF (mm/dd/yyyy) _____________________ 	

ASSETS (Omit assets of doubtful value)	Even Dollars	LIABILITIES	Even Dollars 	
Cash on hand and in banks		Notes payable to banks - secured		
U.S. Gov’t. & Marketable Securities - See Schedule A		Notes payable to banks - unsecured		
Non-Marketable Securities - See Schedule B		Due to Brokers		
Securities held by broker in margin accounts		Amounts payable to others - secured		
Restricted or control stocks		Amounts payable to others - unsecured		
Partial interests in Real Estate Equities – see ScheduleC		Accounts and bills due		
Real Estate Owned - See Schedule D		Unpaid income tax		
Loans Receivable		Other unpaid taxes and interest		
Automobiles and other personal property		Real estate mortgages payable -  See Schedule D		
Cash value-life insurance - See Schedule E				
Other assets - itemize:		Other debts - itemize:		

		TOTAL LIABILITIES		
		NET WORTH (Total Assets LESS Total Liabilities)		
TOTAL ASSETS		TOTAL LIAB. AND NET WORTH		
		
SOURCES OF INCOME FOR THE YEAR ENDED ___________	PERSONAL INFORMATION	
Salary, bonuses & commissions                                         $	Do you have a will? ___________ If so, name executor.	
Dividends		
Real estate income	Are you a partner or officer in any other venture?  If so, describe.	
Other Income

(Alimony, child support, or separate maintenance Income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)		
	Are you obligated to pay alimony, child support or separate maintenance	
	payments?  If so, describe.	
		
TOTAL                                                                     $	Are any assets pledged other than as described on schedules?  If so, describe.	
CONTINGENT LIABILITIES		
Do you have any contingent liabilities?  If so describe	Income tax settled through (date)___________________________________	
	Are you a defendant in any suites or legal actions?	
As endorser, co-maker or guarantor?                                S	Personal bank accounts carried at	
On leases or contracts?                                                     $	Phone # _________________________ Acct # _________________________	
Legal Claims                                                                      $ 	Contact:________________________________________________________	
Other special debt                                                              $	Have you ever been declared bankrupt?  If so, describe	
Amount of contested income tax liens                               $		

SCHEDULE A - U.S. GOVERNMENTS & MARKETABLE SECURITIES
Number of Shares
or Face Value (Bonds)	Description	In Name Of	Are These Pledged?	Market
Value	

					

SCHEDULE B - NON-MARKETABLE SECURITIES
Number of Shares	Description 	In Name Of	Are These Pledged?	Value	

					

SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE EQUITIES
Address & Type 
Of Property	Title In
Name Of	% of
Ownership	Date
Acquired	Cost	Market
Value	Mortgage
Maturity	Mortgage
Amount	

								

SCHEDULE D - REAL ESTATE OWNED
Address & Type
Of Property	Title In
Name Of	Date
Acquired	Cost	Market
Value	Mortgage
Maturity	Mortgage
Amount	

							

SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP INSURANCE
Name Of
Insurance Company	Owner Of
Policy	Beneficiary	Face Amount	Policy
Loans	Cash Surrender
Value	

						

SCHEDULE F - BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name & Address
Of Lender	Credit In
The Name Of	Secured Or
Unsecured	Original
Date	High
Credit	Current
Balance	

						

The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor.  Each undersigned understands that you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit.  Each undersigned represents and warrants that the information provided is true and complete and that you may consider this statement as continuing to be true and correct until a written notice of a change is given to you by the undersigned.  You are authorized to make all inquiries you deem necessary to verify the accuracy of the statements made herein, and to determine my/our creditworthiness.  You are authorized to answer questions about your credit experience with me/us.
							Signature (Individual)____________________________________
Date Signed:_________________________ 19 _______	S.S. No._____________________Date of Birth_______________

							Signature (Other Party)__________________________________
Date Signed:_________________________ 19 _______	S.S. No._____________________Date of Birth_______________