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Personal Financial Statement
Important Applicant Information: Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several questions and to provide one or more forms of identification to fulfill this requirement. In some instances we may use outside sources to confirm the information. The format you provide is protected by our privacy policy and federal law.

Please choose recipient:
Type of Credit Requested:
 
Secured
Individual Credit - relying soley on my income or assets
Unsecured
Individual Credit - relying on my income or assets as well as income or assets from other sources
Joint Credit - We intend to apply for joint credit
Amount requested:
For how long?
Payment date desired:
Want to repay:
Monthly
Other
Proceeds of loan to be used for:
Applicant information
First name:
Last name:
Middle name:
Birthdate:
Telephone number:
Driver's license number:
Social Security number:
Number of dependents:
Ages of dependents:
Address: (street, city, state, zip):
County:
Do you:
Own
Rent
How long:
Previous Address: (street, city, state, zip):
(complete if less than 3 years at present address)
County:
Did you:
Own
Rent
How long:
Employer: (company name and address)
How long:
Business phone:
Position or title:
How long:

Salary per month:

Gross Salary:

Net Salary:

Previous employer: (company name and address)

How long:

Name & address of nearest relative not living with you:

Relationship:

Telephone Number: (include area code)

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.

Alimony, child support, separate maintenance received under:

Court order
Written agreement
Oral understanding

Sources of other income:

Amount per month:

Is any income listed in this section likely to be reduced before the credit request is paid off?:

No
Yes (explain below)

If yes, explain:

Have you previously received credit from us?:

No
Yes (explain below)
when?
Co-Applicant / other party information
First name:
Last name:
Middle name:
Birthdate:
Telephone number:
Driver's license number:
Social Security number:
Number of dependents:
Ages of dependents:
Relationship to applicant: (if any)
Present Address: (street, city, state, zip):
How long:
Employer: (company name and address)
How long:
Business phone:
Position or title:

Salary per month:

Gross Salary:

Net Salary:

Previous employer: (company name and address)

How long:

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.

Alimony, child support, separate maintenance received under:

Court order
Written agreement
Oral understanding

Sources of other income:

Amount per month:

Is any income listed in this section likely to be reduced before the credit request is paid off?:

No
Yes (explain below)

If yes, explain:

Has joint applicant or other party previously received credit from us?:

No
Yes (explain below)
when?
Marital Status
Applicant:
Married
Separated
Unmarried
Other Party:
Married
Separated
Unmarried
assets owned
Description of Assets
Checking Account Numbers
Where
Name in which account is carried
Subject to Debt?
Value
         
Savings Account Numbers
Where
Name in which account is carried
Subject to Debt?
Value
         
Certificate of Deposits
Where
Name in which account is carried
Subject to Debt?
Value
         
Marketable Securities
Issuer, Type,
No. of Shares
Name in which account is carried
Subject to Debt?
Value
         
Real Estate
Location, Date Acquired
Name in which account is carried
Subject to Debt?
Value
         
Life Insurance
Issuer, Face Value
Name in which account is carried
Subject to Debt?
Value
         
Automobiles
Make, Model, Year
Name in which account is carried
Subject to Debt?
Value
Other (list)
Name in which account is carried
Subject to Debt?
Value
 
         
Total Assets
     
outstanding debts
Include charge accounts, Installment Contracts, Credit Cards, Rent, Mortgages and other obligations.
Creditor:
Landlord or
mortgage
holder
Account Number
Name in which account is carried
Original
amount
(omit rent)
Present balance
(omit rent)
Monthly payments
Rent Pmt
Mortgage

 

           
Creditor:
Automobiles
(describe)
Account
Number
Name in which account is carried Original
amount
(omit rent)
Present balance
(omit rent)
Monthly payments
           
Total Debts    

Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable):

Are you obligated to make Alimony, Support or Maintenance Payments?:

No
Yes

If yes, to (name and address):

Amount per month:

Are you a co-maker, endorser, or guarantor on any loan or contract?:

No
Yes

If yes, for whom?:

To whom?:

Are there any unsatisfied judgments against you?:

No
Yes

If yes, to whom owed?:

Amount:

Have you been declared bankrupt in the last 10 years?:

No
Yes

If yes, where?:

What year?:

property information

Property description:

Names & addresses of all co-owners of the property:

If the security is real estate, give the full name of your spouse (if any):

signatures

I certify that everything I have stated in this application and on any attachments is correct. Lender may keep this application whether or not it is approved. By signing below I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. I understand that I must update credit information at Lender's request if my financial condition changes.

Applicant Signature:
Date:

 
Other Signature:
Date:



Please print this application before pressing the submit button.
Thank you.
FDIC
Member FDIC
First National Bank

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