Financial Statement

Financial Statement.doc (81.1 KiB)




 

Financial Statement

 

Borrower

Name: _________________________
Current Mailing Address:__________
_______________________________
City:_____________________
State:____________________
Zip:______________________

Telephone Day:___________________
Telephone Evening:________________

Social Security Number:____-___-____

# of Dependants:___

Ages of Dependants:___  ___  ___  ___

Are you currently employed? _________

Length of Employment (months): ___

Gross income: $_________

Paycheck deductions:
Medical Insurance: $________

Life Insurance: $________

Retirement: $_______

Profit Sharing: $________

Other Deductions: $________

Explain:______________
____________________

What is your pay cycle?____________

Monthly Net income? _____________

Do you receive a monthly bonus? _____
Amount: $________

Co-Borrower

Name: ___________________________
Current Mailing Address:____________
_________________________________
City:_______________________
State:______________________
Zip:_______________________

Telephone Day:____________________
Telephone Evening:_________________

Social Security Number:____-___-____

# of Dependants:___

Ages of Dependants:___  ___  ___  ___

Are you currently employed? _________

Length of Employment (months): ___

Gross income: $_________

Paycheck deductions:
Medical Insurance: $________

Life Insurance: $________

Retirement: $_______

Profit Sharing: $________

Other Deductions: $________

Explain:______________
____________________

What is your pay cycle?____________

Monthly Net income? _____________

Do you receive a monthly bonus? _____
Amount: $________

Do you receive overtime/commission?__
Amount$______

Is this amount earned:

Are you self employed? ______        If yes, date of last employment    _______

Former Gross monthly Income: $____

Total Severance Package Value:
$________

Monthly Unemployment Pay:
$________

Do you receive Child Support? ___
Total monthly Payments?
$___________
expiration date_________

Do you receive alimony? ___
Total monthly Payments?
$__________
expiration date:________

Other Income:
Source:______

For which year did you last file a tax return?______
Gross Income: $__________
Interest Income $_________
Dividend Income: $_______

If you did not file a tax return last year explain why? _____________________
_________________________________

Total Checking Balance: $___________

Name and address of financial Institution:

Do you receive overtime/commission?__
Amount$______

Is this amount earned:

Are you self employed? ______        If yes, date of last employment    _______

Former Gross monthly Income: $____

Total Severance Package Value:
$________

Monthly Unemployment Pay:
$________

Do you receive Child Support? ___
Total monthly Payments?
$___________
expiration date_________

Do you receive alimony? ___
Total monthly Payments?
$__________
expiration date:________

Other Income:
Source:______

For which year did you last file a tax return?______
Gross Income: $__________
Interest Income $_________
Dividend Income: $_______

If you did not file a tax return last year explain why? _____________________
_________________________________

Total Checking Balance: $___________

Name and address of financial Institution:
Account Number:__________________

Total Savings Balance: $___________

Name and address of financial Institution:

Account Number: __________________

Company Retirement Account:
$_______________

Total 401k/IRA: $____________

Total Investments:
Stocks: $__________
Bonds: $__________
Other Securities: $_______
Other: $_________

Total other assets:
Cash value of Life Insurance?
$___________
Notes Payable to you?
$___________
Personal Property: $ ________
Vehicles: $ ____________
Others: $ ___________

How many properties do you own? ____
For each property (attach a separate sheet for more that one)

Current Value: $_____________
Monthly Rental: $____________
Debt on Property: $___________
Is the debt past due:________
Monthly homeowners dues: $___

Account Number:__________________

Total Savings Balance: $___________

Name and address of financial Institution:

Account Number: __________________

Company Retirement Account:
$_______________

Total 401k/IRA: $____________

Total Investments:
Stocks: $__________
Bonds: $__________
Other Securities: $_______
Other: $_________

Total other assets:
Cash value of Life Insurance?
$___________
Notes Payable to you?
$___________
Personal Property: $ ________
Vehicles: $ ____________
Others: $ ___________

How many properties do you own? ____
For each property (attach a separate sheet for more that one)

Current Value: $_____________
Monthly Rental: $____________
Debt on Property: $___________
Is the debt past due:________
Monthly homeowners dues: $___

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