|Address:||Social Security Number:|
|Position or Occupation:||Home Phone:|
|Business Name:||Business Phone:|
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.
|Cash on Hand and in Banks (Schedule A)||$|
|Gov't and Listed Securities (Schedule B)||$|
|Unlisted Securities (Schedule B)||$|
|Real Estate Owned (Schedule D)||$|
|Other Personal Property||$|
|Cash Value Life Insurance (Schedule C)||$|
|Securities Held by Brokers in Margin Accounts||$|
|Equity in Partnership or||$|
|Other Assets: (Itemize Below)||$|
|Notes Payable - Banks/Secured (Schedule E)||$|
|Notes Payable - Banks/Unsecured (Schedule E)||$|
|Notes Payable Others (Schedule E)||$|
|Life Insurance Loans (Schedule C)||$|
|Due to Brokers||$|
|Unpaid Income Taxes||$|
|Real Estate Mortgages Payable (Schedule D)||$|
|Real Estate Taxes||$|
|Other Debts: (Itemize Below)||$|
|TOTAL LIABILITIES & NET WORTH||$|
|SOURCES OF INCOME FOR YEAR ENDED 19||AMOUNT|
|Salaries and Bonuses||$|
|Dividends and Interest||$|
* Income from Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not wish the Bank to consider this income in determining your credit worthiness.
|As Endorser, Co-Maker, or Guarantor||$|
|On Lease or Contracts||$|
|Other (Describe Below)||$|
|TOTAL CONTINGENT LIABILITIES||$|
Are any assets pledged or restricted other than indicated on following schedules? If so, describe.