CONFIDENTIAL
B LIFE INSURANCE
(List only those Policies that you own)
Company
Cash Surrender
Value
Policy Loan from
Insurance Co.
Other Loans Policy
as Collateral
$0.00 $0.00
C SECURITIES OWNED
Face Value-Bonds
No. of Shares Stock Type of Ownership COST
Market Value
.
.
Gov. Sec.
Market Value
Marketable Sec.
TOTALS $0.00 $0.00
D NOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually-Indicate by a X if Others have an Ownership Interest)
X
When Due Original Amount
Balance
ue
ood
Accounts
Balance
ue
Doubtful Accounts
Bal.
ue
otes
el. &
Friends
TOTALS $0.00 $0.00 $0.00
E REAL ESTATE OWNED (Indicate by a X if Others have an Ownership Interest)
M
OF
escription &
Location
X
Date Acquired Original Cost
Present Value of
eal
Estate
mount of
ns.
Carried Bal. Due Payment Maturity To Whom Payable
TOTAL $0.00 TOTAL $0.00
F MORTGAGES AND CONTRACTS OWNED (Indicate by a if Others have an Ownership Interest)
Contract Mortgage X Maker Name Maker Address Start Date Payment Maturity Balance Due
TOTALS $0.00
G PERSONAL PROPERTY (Indicate by a X if Others have an Ownership Interest)
X
Date When New Cost When New Value Today Balance Due
TOTAL $0.00
H NOTES (Other than Bank, Mortgage and Insurance Company Loans)
ther
bligors (if
any) When Due
otes
ue
o
el. &
Friends
otes
ue '
thers'
(Not Banks)
ccounts & Bills
Payable Contracts Payable
TOTALS $0.00 $0.00 $0.00 $0.00
Signature: Signature: Date:
SECTION II (
Continued)
BENEFICIARY
ndicate those
ot
Registered in Your
M
K
V
ot
eadily Marketable
SECURITIES Amount Pledged to Secured Loans
$0.00
MAKER/DEBTOR Security (if any)
Pro
ert
Covered
DESCRIPTION To Whom Pa
able
For the purpose of procuring credit from time to time, I/We furnish the foregoing as a true and accurate statement of my/our financial condition.
Authorization is hereby given to the Lender to verify in any manner it deems appropriate any and all items indicated on this statement. The undersigned also
agrees to notify the Lender immediately in writing of any significant adverse change in such financial condition.
Face of Polic
TOTALS
MORTGAGE OR CONTRACT PAYABLE
PAYABLE TO COLLATERAL (if any)
PERSONAL FINANCIAL STATEMENT 1
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signature
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