Personal Financial Statement - CONFIDENTIAL
Mid America Banklease Corp.

Name: Date:
Address: Social Security Number:
Position or Occupation: Home Phone:
Business Name: Business Phone:
Business Address:

The following is submitted for the purpose of procuring, establishing, and 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. You are authorized to make all inquiries you deem necessary to verify the accuracy of the statement made herein, and to determine my/our creditworthiness. You are authorized to answer questions about your credit experience with me/us.

Fill ALL blanks to the nearest hundred. If not applicable, write NONE.

ASSETS AMOUNT
Cash on Hand and in Banks (Schedule A) $
Gov't and Listed Securities (Schedule B) $
Unlisted Securities (Schedule B) $
Loans Receivable $
Real Estate Owned (Schedule D) $
Homestead $
Automobiles $
Other Personal Property $
Cash Value Life Insurance (Schedule C) $
Securities Held by Brokers in Margin Accounts $
Equity in Partnership or $
Proprietorship $
Other Assets: (Itemize Below) $
- $
- $
- $
TOTAL ASSETS $
LIABILITIES AMOUNT
Notes Payable - Banks/Secured (Schedule E) $
Notes Payable - Banks/Unsecured (Schedule E) $
Notes Payable Others (Schedule E) $
Life Insurance Loans (Schedule C) $
Due to Brokers $
Accounts Payable $
Unpaid Income Taxes $
Real Estate Mortgages Payable (Schedule D) $
Real Estate Taxes $
Credit Cards $
Other Debts: (Itemize Below) $
- $
- $
Total Liabilities $
Net Worth $
TOTAL LIABILITIES & NET WORTH $
SOURCES OF INCOME FOR YEAR ENDED 19 AMOUNT
Salaries and Bonuses $
Commissions $
Dividends and Interest $
Real Estate $
Other * $
TOTAL INCOME $

* Income from Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not wish the Bank to consider this income in determining your credit worthiness.

CONTINGENT LIABILITIES AMOUNT
As Endorser, Co-Maker, or Guarantor $
On Lease or Contracts $
Legal Claims $
Other (Describe Below) $
- $
TOTAL CONTINGENT LIABILITIES $

 

 

PERSONAL INFORMATION

Are any assets pledged or restricted other than indicated on following schedules? If so, describe.


Are you a defendant in any legal actions or suits? If so, describe.


Are you a partner or officer in any other venture? If so, describe.


Do you have a will? If so, name of Personal Representative.


Have you ever been declared Bankrupt? If so, describe.


COMPLETE SCHEDULES AND SIGN ON REVERSE