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[]
["PERSONAL FINANCIAL STATEMENT"]
[]
["FINANCIAL CONDITION AS OF (DATE):"]
[]
["Applicant"]
["Name:",{"$nulls":8},"Social Security #"]
["Address:",{"$nulls":8},"Date of Birth:"]
["Present Employer:",{"$nulls":8},"Home Phone #"]
["Address:",{"$nulls":8},"Business Phone #"]
["Position:",{"$nulls":8},"Cell Phone #"]
["Email Address:",{"$nulls":8},"Drivers License #"]
[{"$nulls":9},"Expiration Date:"]
["Co-Applicant"]
["Name:",{"$nulls":8},"Social Security #"]
["Address:",{"$nulls":8},"Date of Birth:"]
["Present Employer:",{"$nulls":8},"Home Phone #"]
["Address:",{"$nulls":8},"Business Phone #"]
["Position:",{"$nulls":8},"Cell Phone #"]
["Email Address:",{"$nulls":8},"Drivers License #"]
[{"$nulls":9},"Expiration Date:"]
[]
["ASSETS",{"$nulls":4},"AMOUNT",null,"LIABILITIES",{"$nulls":4},"AMOUNT"]
["Cash in this Bank",{"$nulls":6},"Notes Payable Banks (Sched. 6)",{"$nulls":4},0]
["Cash in other Banks (Detail)",{"$nulls":6},"Notes Payable Others (Sched. 7)",{"$nulls":4},0]
[{"$nulls":7},"Installment Contracts Payable (Sched. 8)",{"$nulls":4},0]
[{"$nulls":7},"Due Dept . Stores, Credit Cards & Others (Sched. 9)",{"$nulls":4},0]
[]
["Due from Friends, Relatives & Others (Sched. 1)",{"$nulls":4},0,null,"Income Taxes Payable"]
[]
[{"$nulls":7},"Other Taxes Payable"]
["Mortgage & contracts for Deed Owned (Sched. 2)"]
["Securities Owned (Sched. 3)",{"$nulls":4},0,null,"Loans on Life Insurance (Sched. 3)",{"$nulls":4},0]
["Cash Surrender Value of Life Insur. (Sched. 4)"]
["Homestead (Sched. 5)",{"$nulls":4},0,null,"Mortgage on Homestead (Sched. 10)",{"$nulls":4},0]
["Other Real Estate Owned (Sched. 5)",{"$nulls":4},0,null,"Mortgage or Liens on Other Real Estate "]
["Automobiles",{"$nulls":6},"    Owned (Sched. 10)",{"$nulls":4},0]
[]
[]
[{"$nulls":7},"Other Liabilities (detail)"]
[]
["Personal Property"]
["  Camper/Fish House"]
[]
[]
[]
[]
[]
[{"$nulls":7},"TOTAL LIABILITIES",{"$nulls":4},0]
[{"$nulls":7},"NET WORTH (Total Assets less Total Liabilities)",{"$nulls":4},0]
["TOTAL",{"$nulls":4},0,null,"TOTAL",{"$nulls":4},0]
[]
[]
["ANNUAL INCOME",null,null,"APPLICANT",null,"CO-APPLICANT",null,"CONTINGENT LIABILITIES"]
["Salary",{"$nulls":6},"As Endorser"]
["Commissions",{"$nulls":6},"As Guarantor"]
["dividends",{"$nulls":6},"Lawsuits"]
["Interest",{"$nulls":6},"For Taxes"]
["Rentals",{"$nulls":6},"Other (Detail)"]
["Alimony, Child support or maintenance (you need not show this unlesss you wish us to consider it)."]
[]
[]
[]
["Other"]
["Contract for Deed"]
[]
["TOTAL INCOME",null,null,0,null,0,null,"TOTAL CONTINGENT LIABILITIES",{"$nulls":4},0]
[]
["SCHEDULE 1  DUE FROM FRIENDS, RELATIVES & OTHERS"]
["Name of Debtor",null,null,"Owed To",null,"Collateral",null,"How Payable",null,null,"Maturity Date",null,"Unpaid Balance"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 2 MORTGAGE & CONTRACTS FOR DEED OWNED"]
["Name of Debtor",null,null,"Type of Property",null,"1st or 2nd Lien","Owed To",null,null,"How Payable",null,null,"Unpaid Balance"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":10},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 3 SECURITIES OWNED"]
["No. Shares or Bond Amount","Description",null,null,"In Whose Name(s) Registered",null,null,null,"Cost",null,"Present Market Value",null," L - listed                    U - unlisted"]
{"$rows_empty":9}
[{"$nulls":7},"TOTAL",0,null,0]
[]
["SCHEDULE 4 LIFE INSURANCE"]
["Insured",null,"Insurance Company",null,null,"Beneficiary",null,null,"Face Value of Policy",null,"Cash Value",null,"Loans"]
{"$rows_empty":8}
[{"$nulls":8},"TOTAL",null,0,null,0]
[]
["SCHEDULE 5 REAL ESTATE"]
["Address and Type of Property",null,null,"Title in Name (s) of",null,null,"Monthly Income",null,"Cost                   Year Acquired",null,"Present Market Value",null,"Amount of Insurance"]
[{"$nulls":6},0]
[]
[{"$nulls":6},0]
{"$rows_empty":19}
[{"$nulls":8},"TOTAL",null,0]
[]
[]
["SCHEDULE 6 NOTES PAYABLE BANKS"]
["To Whom Payable",{"$nulls":6},"How Payable",null,null,"Rate","Maturity Date","Unpaid Balance"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 7 NOTES PAYABLE OTHERS"]
["To Whom Payable",{"$nulls":6},"How Payable",null,null,"Rate","Maturity Date","Unpaid Balance"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 8 INSTALLMENT CONTRACTS PAYABLE"]
["To Whom Payable",{"$nulls":6},"How Payable",null,null,"Rate","Maturity Date","Unpaid Balance"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 9 DUE DEPT. STORES, CREDIT CARDS, OTHERS"]
["To Whom Payable",{"$nulls":6},"How Payable",null,null,"Rate","Maturity Date","Unpaid Balance"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
["SCHEDULE 10 MORTGAGES REAL ESTATE"]
["To Whom Payable/Property Address",{"$nulls":6},"How Payable",null,null,"Rate","Maturity Date","Unpaid Balance"]
["Homestead:",{"$nulls":7},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":8},"per","month"]
[{"$nulls":11},"TOTAL",0]
[]
[{"$nulls":5},"Applicant",null,null,null,"Co-Applicant"]
[]
["Have you ever gone through bankruptcy or had a judgement",{"$nulls":5},"Yes",null,"No",null,"Yes",null,"No"]
[]
["Are any assets pledge or debrts secured except as shown?",{"$nulls":5},"Yes",null,"No",null,"Yes",null,"No"]
[]
["Have you made a will?",{"$nulls":5},"Yes",null,"No",null,"Yes",null,"No"]
[]
["Number of Dependents (If \"none\" check None)",{"$nulls":7},"None",null,null,null,"None"]
[]
["Marital Status (answer only if this financial statement is provided in connection with a request for secured credit or applicant is seeking a joint account with spouse.)",{"$nulls":6},"Married",null,null,null,"Married"]
[]
[{"$nulls":7},"Separated",null,null,null,"Separated"]
[]
[{"$nulls":7},"Unmarried",null,null,null,"Unmarried"]
[{"$nulls":7},"(Unmaried inlcudes single, divorced, widowed)"]
[]
["For the purpose of obtaining loans and discounting paper with you, and otherwise procuring credit from time to time, I/we furnish the following true and accurate statement of my financial condition.  I/we agree to and will notify you immediately in writing of any materially unfavorable change in my/our financial condition, and in the absence of such notice or of a new and full written statement, this may be considered as a continuing statement and substantially correct; and it is hereby expressly agreed that upon application for futher credit, this statement shall have the same force and effect as if delivered as an original statement of my financial condition at the time such further credit is requested.  I/we understand that you will retain this personal financial statement whether or not you approve the credit in connection with which it is submitted.  Your are authorized to check my/our credit and employment history or any other information contained herein."]
[]
["THE UNDERSIGNED CERTIFY THAT THE INFORMATIN CONTAINED ON THIS FORM "]
["HAS BEEN CAREFULLY REVIEWED AND THAT IT IS TRUE AND CORRECT IN ALL RESPECTS."]
[]
[]
["Date",{"$nulls":5},"Applicant Signature"]
[]
[]
[]
["Date",{"$nulls":5},"Co-applicant Signature (if you are requesting the financial accommodation jointly)"]

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