STATEMENTINDIVIDUAL FINANCIAL
statementIMPORTANT: Date and sign
("Lender")
theFor the purpose of obtaining credit from Lender and any future credit granted by Lender, or to support the extension of credit already given, I make
property.This statement is Lender's . following statement to Lender of my financial condition on
Name
Address
To
amI only:
For Wisconsin residents married unmarried separatedlegally
Name of spouse Address
NECESSARYCOMPLETE ALL BLANKS, WRITING "NO" OR "NONE" WHERE
ASSETS
SPOUSELIABILITIES OF APPLICANT AND
SOURCES OF INCOME FOR YEAR ENDED SPOUSECONTINGENT LIABILITIES OF APPLICANT AND
WORTHTOTAL LIABILITIES and NET
ASSETSTOTAL
INFORMATIONPERSONAL
Home Telephone
No.Social Security
Applicant(s)Employer(s) of
describe.Are any assets pledged or restricted other than indicated on following schedules? If so,
Are you a defendant in any legal actions or suits? If so, describe.
describe.Are you a partner or officer in any other venture? If so,
Representative.If so, name of Personal No Yes Do you have a will?
describe.Have you ever been declared Bankrupt? If so,
*For Married Wisconsin residents, name each spouse and include the income of each spouse.
**Income from Alimony, Child Support or Separate Maintenance income and income from medical insurance, disability or wage continuation insurance
need not be revealed if you do not wish the Lender to consider this income on determining your creditworthiness.
LiabilitiesTotal
WorthAssets less Liabilities = Net
COMPLETE SCHEDULES AND SIGN ON PAGE 2
statement:For purposes of this
andMarital property means assets acquired with my or my spouse's income on or after 1-1-86;
Individual property means property owned (whether in joint or sole name) by me prior to marriage, prior to establishing residence in Wisconsin, or
time.prior to 1-1-86, however acquired, and property acquired by me by gift or inheritance at any
BELOW:INSTRUCTIONS FOR INFORMATION TO BE SUPPLIED
aIf married applicants are applying for joint credit, include all assets and all liabilities of both spouses. Both spouses must sign this statement. If
allmarried applicant is applying for separate credit or for joint credit with someone other than his or her spouse, include all marital property and
statement.include individual property of the other spouse. Only the applicant must sign this not
do individual property of the applicant spouse but
decreeNo provision of any marital property agreement, unilateral statement under § 766.59, Wis. Stats., or court
APPLICANTS: NOTICE TO MARRIED
creditunder § 766.70, Wis. Stats., adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted or an open-end
provision.plan is entered into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse
Cash on Hand and in Financial Institutions (Schedule A)
Gov't and Listed Securities (Schedule B)
B)Unlisted Securities (Schedule
Notes and Loans Receivable (Schedule F)
D)Homestead and Real Estate Owned (Schedule
Automobiles
PropertyOther Personal
C)Cash Value Life Insurance (Schedule
Accts.Securities Held by Brokers in Margin
PartnershipEquity in
ProprietorshipEquity in
SharingVested Pension Benefits or Profit
Other Assets: (Itemize Below)
*Salaries & Bonuses
Commissions
InterestDividends &
EstateReal
**Other
GuarantorAs Endorser, Co-Maker, or
ContractsOn Lease or
ClaimsLegal
(describe)Other
$
$
$
$
$
$
$
$
$
$
$
$
$
127 (4/06)
11031
A.W. B.
2006 Wisconsin Bankers Association / Distributed by FIPCO®©
BirthDate of StateDriver's License No. and
StatementDate of Financial
(Schedule E) Notes Payable - Lenders/Secured
Notes Payable - Lenders/Unsecured (Schedule E)
Notes Payable Others (Schedule E)
Life Insurance Loans (Schedule C)
Due to Brokers
Accounts Payable
Unpaid Income Taxes
Real Estate Mortgage Payable (Schedule D)
Real Estate Taxes
CardsCredit
Below)Other Debts (Itemize
