Welcome To DeMotte

Schedule E - Business Ventures

List Name and address of any Business Venture in which you are a principal or partner

Book Value

Your % Ownership

Your Position/Title
in the business

Total Assets of Business

Line of Business

Years in Business

CONFIDENTIAL PERSONAL FINANCIAL STATEMENT

You may complete this form in one of two ways:

1. Enter your information in the form provided below and print by activating the print button at the end of the form, or;

2. Click here for a printable form which may be used if you prefer to complete the form manually.

IMPORTANT: Read these directions before completing this Statement

If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested, complete only Sections 1,3 and 4.
If you are applying for joint credit with another person, complete all Sections and provide information in Section 2 about the joint applicant. If appropriate the joint applicant may complete a separate personal financial statement, and the applications may be submitted together.
If you are applying for individual credit but are relying on income from alimony, child support or separate maintenance or on the income or assets of another person as a basis for repayment of the credit requested, complete all Sections. Provide information in Section 2 about the person whose alimony, support or maintenance payments or income or assets you are relying on. 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.
If this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporation(s), complete all sections.
Please do not leave any questions unanswered. Use "no" or "none" where necessary.

Section 1 Individual Information

Name:

Address:

City: State: Zip:

Position and Occupation:

Business Name:

Business Address:

City: State: Zip:

Length of Employment:

Res. Phone: Bus. Phone:

Section 2 Other Party Information (Type or Print)

Name:

Address:

City: State: Zip:

Position and Occupation:

Business Name:

Business Address:

City: State: Zip:

Length of Employment:

Res. Phone: Bus. Phone:

Section 3 Statement of Financial Condition as of
	(day)	(month)	(year)

Assests (Do not include assests of doubtful value)	In Dollars (Omit cents)	Liabilities	In Dollars (Omit cents)
Cash on hand in this bank-see schedule A	$	Accounts and Bill Due	$
Cash in other banks, savings & loans, etc-see schedule A		Auto Loans Payable-See schedule F
US Government & Marketable securities-see schedule B		Notes Payable Banks-see schdule F
Cash Value - life insurance-see schedule C		Notes Payable to other institutions-see schedule F
IRA accounts and/or vested interest in retirement fund		Notes Payable to individuals and others-see schedule F
Collectable accounts, loans and other notes receivable		Due to Brokers
		Unpaid Income Tax
TOTAL CURRENT ASSETS		Unpaid Real Estate or other taxes

Real Estate owned-see schedule D		Unpaid Interest
Automobiles		TOTAL CURRENT LIABILITIES

		Real Estate Mortgages Payable-see schedule D
Non-marketable securities-see schedule B		Real Estate Contracts Payable-see schedule D
Book Value of business ventures-see schedule E		Life Insurance Loans-see schedule C
Personal Property		Other debts-itemize
Other Assets - itemize
		TOTAL LIABILITIES
		NET WORTH
TOTAL ASSETS	$	TOTAL LIABILITIES & NET WORTH	$

Section 4 Sources of Income (or submit copy of tax return)
Annual Expenditures
FOR YEAR ENDED		Mortgage/rental payments
Salary/bonuses & commissions		Real estate taxes & assessments
Dividends & interest		Taxes-Federal, State & Local
Real Estate Income		Insurance payments
Other income, alimony, child support or separate maintenance income need not be revealed if you do not with to have it considered as a basis for repaying this obligation		Other contract payments, car payments, charge cards, etc
		Alimony, child support, Maintenance
		Other expenses
Total Income $		Total Expenditures $

General Information

Employer:

Position or Profession: No. years:

Employer's Address:

Phone Number:

Partner, officer or owner in any other venture? No Yes
If so, explain:

Are any assets pledged? No Yes Detail in Schedule A

Income Taxes settled through (Date)

Are you a defendant in any Suits of Legal Action? No Yes
If so, explain:

Contingent Liabilities
As endorser, co-maker or guarantor	$	Have you ever taken bankruptcy? No Yes If so, explain
On Leases
Legal Claims		Do you have a will? No Yes With Whom?
Provision for Federal Income Taxes
Other special debt e.g., recourse or repurchase liability		Do you have a trust? No Yes With Whom?

Schedule A - Banks, Savings & Loans, Credit Unions, etc., where funds are on deposit
Name of Institution	Address	Type of Deposit	Name of Owner	Amount

Schedule B - U.S. Governments, Marketable & Non-marketable Securities
Number of shares on face value of bond	Description	In Name of	Market Value	Source of Value

Schedule C - Life Insurance carried, including Group Insurance
Name of Insurance Co.	Owner of Policy	Beneficiary	Face Amount	Policy Loans	Cash Surrender Value

Schedule D - Real Estate (Wholly or Partially Owned)
Address and Type of Property	Title in name of	% of ownership	Date acquired	Cost	Maket Value	Mortgage or Contract Balance	Mortgage or Contract Maturity	Mortgage Holder or Contract Seller
Residence
Other
Other
Other

Schedule F - Loans/Notes Payable
Name and address of Creditor	Purpose of Loan	Original Loan/Line Amount	Date of Loan Schedule	Maturity Date Payment	Unsecured or Secured List Collateral	Current Balance	Payment Schedule

The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of the undersigned. The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents warrants and certifies that the information provided herein is true, correct and complete. Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement of (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.