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[null,"INSTRUCTIONS FOR COMPLETING THE PERSONAL FINANCIAL STATEMENT"]
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[null,"If you prefer to use the computer to fill out the form:"]
[null,"1) Fill in all the green-highlighted areas. Using the tab key will automatically move the cursor to those cells which require your input. Cells which aren't highlighted will automatically populate as necessary using the information you input into the schedules on the second page of the form."]
[null,"2) Print out the worksheet."]
[null,"3) Sign and date the second page of the statement. (An e mail copy will not suffice; your signature is required.)"]
[null,"4) Mail it to your loan officer. "]
[]
[null,"If you prefer to fill out the form by hand:"]
[null,"1) Print out the worksheet."]
[null,"2) Fill out every area of the worksheet. (Ignore highlights)"]
[null,"3) Sign and date the second page of the statement. "]
[null,"4) Mail it to your loan officer. "]
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[null,"Thank you!"]
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[null,null,"PERSONAL FINANCIAL STATEMENT"]
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["IMPORTANT: Read these directions before completing this Statement."]
["l","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 and 3."]
["l","If you are applying for joint credit with another person, complete all Sections providing information in Section 2 about the joint applicant "]
["l","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 providing information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying."]
["l","If this statement relates to your guaranty of the Indebtedness of other person(s), firm(s) or corporation(s), complete Sections 1 and 3."]
["TO:                                                                                                                                                                               Bank of Washington     \nPO Box 377 | Washington, MO 63090\n636.239.7831 | bankofwashington.com"]
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["SECTION 1 - INDIVIDUAL INFORMATION           (Type or Print)   ",{"$nulls":22},"SECTION 2 - OTHER PARTY INFORMATION       (Type or Print)   "]
["Name",{"$nulls":22},"Name"]
["Residence Address",{"$nulls":22},"Residence Address"]
["City, State & Zip",{"$nulls":22},"City, State & Zip"]
["S. S. No.",{"$nulls":22},"S. S. No."]
["Date of Birth",{"$nulls":22},"Date of Birth"]
["Position or Occupation",{"$nulls":22},"Position or Occupation"]
["Business Name",{"$nulls":14},"Yrs. Employed:",{"$nulls":7},"Business Name",{"$nulls":14},"Yrs. Employed:"]
["Business Address",{"$nulls":22},"Business Address"]
["City, State & Zip",{"$nulls":22},"City, State & Zip"]
["Res. Phone",{"$nulls":12},"Bus. Phone",{"$nulls":9},"Res. Phone",{"$nulls":12},"Bus. Phone"]
["SECTION 3 - STATEMENT OF FINANCIAL CONDITION"]
["AS OF DATE:"]
["ASSETS\n(Do not include Assets of doubtful value)",{"$nulls":12},"In Dollars",{"$nulls":4},"In Dollars",{"$nulls":4},"LIABILITIES",{"$nulls":12},"In Dollars",{"$nulls":4},"In Dollars"]
[{"$nulls":13},"(Omit cents)",{"$nulls":4},"(Omit cents)",{"$nulls":17},"(Omit cents)",{"$nulls":4},"(Omit cents)"]
[{"$nulls":13},"Individual ",{"$nulls":4},"Joint",{"$nulls":17},"Individual ",{"$nulls":4},"Joint"]
["Cash on hand and in banks",{"$nulls":22},"Notes payable to banks - secured (see Schedule F)"]
["U S Gov't & Marketable Securities - see Schedule A",{"$nulls":22},"Notes payable to banks - unsecured (see Schedule F)"]
["Non-Marketable Securities - see Schedule B",{"$nulls":22},"Due to brokers"]
["Securities held by broker in margin accounts",{"$nulls":22},"Amounts payable to others - secured"]
["Restricted or control stocks",{"$nulls":22},"Amounts payable to others - unsecured"]
["Partial interest in Real Estate Equities - ",{"$nulls":22},"Accounts and bills due"]
["see Schedule C",{"$nulls":22},"Unpaid income tax"]
["Real Estate Owned - see Schedule D",{"$nulls":22},"Other unpaid taxes and interest"]
["Loans Receivable",{"$nulls":22},"Real estate mortgages payable - (see Schedule D)"]
["Automobiles and other personal property",{"$nulls":22},"Other debts - itemize"]
["Cash value-life insurance - see Schedule E"]
["Other assets - itemize"]
[]
[]
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[{"$nulls":23},"TOTAL LIABILITIES",{"$nulls":12},0,{"$nulls":4},0]
[{"$nulls":23},"NET WORTH",{"$nulls":12},0,{"$nulls":4},0]
["TOTAL ASSETS",{"$nulls":12},0,{"$nulls":4},0,{"$nulls":4},"TOTAL LIABILITIES AND NET WORTH",{"$nulls":12},0,{"$nulls":4},0]
[]
["SOURCES OF INCOME FOR YEAR ENDED",{"$nulls":12},"Individual",{"$nulls":4},"Other Party",{"$nulls":4},"PERSONAL INFORMATION"]
["Salary, bonuses & commissions",{"$nulls":22},"Do you have a will?",{"$nulls":7},"If so, name executor."]
["Dividends"]
["Real estate income",{"$nulls":22},"Are you a partner or officer in any other venture? If so, describe."]
["Other income (Alimony, child support, or separate maintenance"]
["income need not be revealed if you do not wish to have it",{"$nulls":22},"Are you obligated to pay alimony, child support or separate maintenance payments? If so, describe."]
["considered as a basis for repaying this obligation)"]
[{"$nulls":23},"Are any assets pledged other than as described on schedules? If so, describe."]
[]
["TOTAL",{"$nulls":12},0,{"$nulls":4},0,{"$nulls":4},"Income tax settled through (date)"]
["CONTINGENT LIABILITIES",{"$nulls":22},"Are you a defendant in any suits or legal actions?"]
["Do you have any contingent liabilities? If so, describe."]
[{"$nulls":23},"Personal bank accounts carried at"]
["As endorser, co-maker or guarantor?"]
["On leases or contracts?"]
["Legal claims",{"$nulls":22},"Have you ever been declared bankrupt? If so, describe."]
["Other special debt"]
["Amount of contested income tax liens"]
[]
[]
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["SCHEDULE A - U.S. GOVERNMENT & MARKETABLE SECURITIES"]
["Number of Shares Or Face Value (Bonds)",{"$nulls":6},"Description",{"$nulls":13},"In Name Of",{"$nulls":9},"Are These Pledged?",{"$nulls":6},"Market Value"]
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[]
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["SCHEDULE B - NON-MARKETABLE SECURITIES"]
["Number of Shares",{"$nulls":6},"Description",{"$nulls":11},"In Name Of",{"$nulls":7},"Are These Pledged?",{"$nulls":4},"Source of Value",{"$nulls":6},"Value"]
[]
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["SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE EQUITIES"]
["Address & Type Of Property",{"$nulls":7},"Title In Name Of",{"$nulls":7},"% Of Ownership",null,null,"Date Acquired",null,null,"Cost",null,null,null,"Market Value",null,null,null,"Mortgage Holder",{"$nulls":6},"Mortgage Payment",null,null,"Mortgage Balance"]
[]
[]
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[]
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["SCHEDULE D - REAL ESTATE OWNED"]
["Address & Type Of Property",{"$nulls":9},"Title In Name Of",{"$nulls":8},"Date Acquired",null,null,"Cost",null,null,null,"Market Value",null,null,null,"Mortgage Holder",{"$nulls":6},"Mortgage Payment",null,null,"Mortgage Balance"]
[]
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["SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP INSURANCE"]
["Name Of Insurance Company",{"$nulls":9},"Owner of Policy",{"$nulls":8},"Beneficiary",{"$nulls":7},"Face Amount",{"$nulls":4},"Policy Loans",{"$nulls":6},"Cash Surrender Value"]
[]
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["SCHEDULE F - ALL BANKS OR FINANCE COMPANIES WHERE CREDIT IS OUTSTANDING"]
["Name & Address Of Lender",{"$nulls":10},"Credit In The Name Of",{"$nulls":9},"Collateral",{"$nulls":6},"Original Date",null,null,"Payment Amount",null,null,"Current Balance",{"$nulls":5},"Original Balance"]
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["The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons, firms, or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor. Each undersigned understands that you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and complete and that you may consider this statement as continuing to be true and correct until a written notice of change is given to you by the undersigned. You are authorized to make all inquiries you deem necessary and to obtain a consumer credit report from any credit reporting agency to verify the accuracy of the statements made herein, in connection with Bank's preliminary evaluation of undersigned, or during any periodic review of undersigned deemed necessary by Bank. You are authorized to answer questions about your credit experience with me/us."]
{"$rows_empty":8}
["Signature (Individual)",{"$nulls":23},"Signature (Other Party)"]
[]
["Date Signed",{"$nulls":23},"Date Signed"]