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P ROJECT, INC. S OUTHEAST R URAL C (County of Campbell)

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BROWSE COUNTY OF CAMPBELL (VA) FORMS

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S OUTHEAST R URAL C OMMUNITY A SSISTANCE
P ROJECT, INC.
PERSONAL F INANCIAL S TATEMENT
________ ________
MO/YR NUMBER
IMPORTANT-Please check one
o Individual – I am applying for individual credit and will rely on my own income and assets to repay any loan.
(Leave blank the spaces that ask about Applicant 2.)
o Joint – We are applying for credit together. We want you to look at all of our income and assets in evaluating this
application. (Complete all sections.)
o Guarantee(s) – I (we) am (are) applying as Guarantor(s) of credit to be extended to ____________________.
o
Amount of Loan Request: $____________________Purpose of Loan ________________________________________
Section 1 – Applicant # 1 (Type or Print) Applicant # 2 (Type or Print)
Name ___________________________________ Name ____________________________________
Address__________________ How Long?______ Address___________________ How Long?______
City, State, Zip____________________________ City, State, Zip______________________________
Position/Occupation________________________ Position/Occupation_________________________
How Long? _______________________________ How Long? ________________________________
Business Name ____________________________ Business Name _____________________________
Business Address __________________________ Business Address ___________________________
City, State, Zip ____________________________ City, State, Zip _____________________________
Res. Phone ____________ Bus. Phone_________ Res. Phone____________Bus. Phone____________
Ages of Dependents ________________________ Ages of Dependents _________________________
Section 2 – Sources of Income for Year Ended: / /
Annual Income #1 #2 Annual Expenditures #1 #2
Salary, Bonuses Mortgage/rental
& Commissions $__________ $__________ payments $___________ $____________
Dividends & Interest ___________ __________ Real estate taxes
& assessments ___________ ___________
Real estate income ___________ __________ Taxes- federal, state
& Local ___________ ___________
Other Income ___________ __________
Insurance Payments ___________ ___________
(alimony, child support, ___________ __________
or separate maintenance Other contract payments ___________ ___________
income need not be (car payments, charge cards, etc)
revealed if you do not ___________ __________
wish to have it considered Alimony, child support,
as a basis for repaying this maintenance ____________ ___________
obligation.)
Other expenses ____________ ___________
Total Income $___________ $ ___________ Total Expenditures $____________ $___________
Southeast Rural Community Assistance Project, Inc. 1
Section 2 – Sources of Income for Year Ended (continued)
Contingent Liabilities
Estimated Amounts #1 #2
Do you have any… YES/NO
Contingent liabilities (as endorser, co-maker or guarantor?)
□ □ ___________ ___________
(On leases? On contracts?)
□ □ ___________ ___________
Involvement in pending legal actions?
□ □ ___________ ___________
Contested income tax liens?
□ □ ___________ ___________
Any estimated capital gains tax on the unrealized
asset appreciation?
□ □ ___________ ___________
Other special debt or circumstances?
□ □ ___________ ___________
If “yes” to any question(s) attach explanations
Total Contingent Liabilities $___________ $ ___________
Face Amount of life insurance #1 _____________________________ #2_________________________________
Please answer Yes or No to the following:
Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than
the amounts owed? If yes, please provide details on a separate sheet………………………………….….._______
Are (either of) you a defendant in any suit or legal action?............................................................................_______
Are (either of) you presently subject to any unsatisfied judgements or tax liens? ………………………....._______
Are (either of) you a partner or officer in any venture?..................................................................................._______
If yes, describe
Are any assets pledged other than as described on schedules?........................................................................_______
If yes, describe
Southeast Rural Community Assistance Project, Inc. 2
Section 3– Statement of Financial Condition as of: / /
ASSETS (do not include Assets of doubtful value)
Indicate ownership with “1” for applicant #1. “2” for applicant #2, #1/ #2/ J In Dollars
And “J” for joint. (omit cents)
Cash on hand and in banks—(See Sched. E) ___________ ________________
U.S Gov’t. & Marketable Securities—(See Sched. A) ___________ ________________
Non-Marketable Securities—(See Shed. A) ___________ ________________
Securities held by broker in margin accounts—(See Sched. A) ___________ ________________
Restricted or control stocks—(See Sched. A) ___________ ________________
Partial interest in Real Estate Equities—(See Sched. B) ___________ _______________
Real Estate owned—(See Sched. C) ___________ ________________
Loans Receivable ___________ ________________
Automobiles and other personal property ___________ ________________
Cash Value—Life Insurance ___________ ________________
Vested interest in Retirement Plan(s) ___________ ________________
Other Assets – itemize: (attach listing if necessary) ___________ ________________
________________________________________________________ ___________ ________________
Total Assets ___________ ________________
Southeast Rural Community Assistance Project, Inc. 3
________________________________________________________ ___________ ________________
________________________________________________________ ___________ ________________
________________________________________________________ ___________ ________________
Section 3– Statement of Financial Condition (continued)
LIABILITIES
Indicate ownership with “1” for applicant #1. “2” for applicant #2, #1/ #2/ J In Dollars
And “J” for joint. (Omit cents)
Notes payable to banks - secured—(See Sched. E) ____________ ________________
Notes Payable to banks – unsecured—(See Sched. E) ____________ ________________
Due to brokers ____________ ________________
Amounts payable to others—secured ____________ ________________
Amounts payable to others—unsecured ____________ ________________
Accounts and bills due ____________ ________________
Unpaid income tax ____________ ________________
Other unpaid taxes and interest ____________ ________________
Real estate mortgages payable – (See Sched. D) ____________ ________________
Other debts-itemize: (attach listing if necessary) ____________ ________________
_________________________________________________________ ____________ ________________
Total Liabilities ____________ ________________
Net Worth ____________ ________________
Total Liabilities & Net Worth ____________ ________________
Southeast Rural Community Assistance Project, Inc. 4
_________________________________________________________ ____________ ________________
_________________________________________________________ ____________ ________________
_________________________________________________________ ____________ ________________
SCHEDULE A – U.S. GOVERNMENT & OTHER SECURITIES (use additional sheet if necessary)
NO. OF SHARES
(STOCK) OR FACE
VALUE (BONDS)
D
ESCRIPTION
MARKETABLE?
IN NAME OF
A
RE THESE
PLEDGED?
MARKET VALUE
SCHEDULE B – PARTIAL INTEREST IN REAL ESTATE EQUITIES (use additional sheet if necessary)
A
DDRESS OF PROPERTY
TYPE
TITLE IN NAME(S) OF
%
OF
OWNED
D
ATE
ACQUIRED
COST
M
ARKET
VALUE
M
ORTGAGE
AMOUNT
*R= Residential C= Commercial L=Land
SCHEDULE C – REAL ESTATE OWNED (use additional sheet if necessary)
A
DDRESS OF PROPERTY
TYPE
TITLE IN NAME(S) OF
ANNUAL INCOME
D
ATE
ACQUIRED
COST
MARKET VALUE
1.
2.
3.
4.
5.
*R= Residential C= Commercial L=Land **Show names of owners or any person having an interest in the property.
SCHEDULE D – MORTGAGE INDEBTEDNESS (use additional sheet if necessary)
PROPERTY NUMBER
FROM
SECTION C
MORTGAGE HOLDER
1
ST
, 2
ND
3
RD
LIEN?
MORTGAGE BALANCE
M
ORTGAGE
MATURITY
MONTHLY PAYMENT
Southeast Rural Community Assistance Project, Inc. 5
SCHEDULE E – BANKS OR OTHER INSTITUTIONS WHERE ACCOUNTS ARE MAINTAINED OR WHERE
CREDIT HAS BEEN OBTAINED
NAME OF
DEPOSITORY
N
AME OF
ACCOUNT
HOLDER
NAME OF JOINT
OWNER OR JOINT
OBLIGOR
BALANCE
ON
DEPOSIT
LOAN
BALANCE
H
OW IS THE
LOAN PAYABLE?
P
AYMENT
AMOUNT
H
OW IS THE
LOAN
SECURED
I authorize you to make whatever credit inquires you consider necessary concerning the statements made in this loan application. I agree that the application
shall remain your property whether or not the loan is granted. I also agree that you may give information regarding my experience with you to credit bureaus
and other proper persons. I have carefully read the answers given above and certify that they are correct to the best of my knowledge. Under penalties of
perjury I certify that I have provided my correct Social Security Number/Taxpayer Identification Number and that I am not subject to Internal Revenue Service
backup withholding. I understand that I have the right to a copy of any appraisal report used in connection with this application if the loan is to be secured by a
dwelling. If I wish a copy, I will write to you at the mailing address you have provided with this application no later than 90 days after you notify me about the
action taken on this application or I withdraw this application.
_____________________________ __________ _____________________________ __________
Applicant #1 Signature Date Applicant #2 Signature Date
________________________________ ___________ ______________________________ __________
Social Security Number Date of Birth Social Security Number Date of Birth
PLEASE PROVIDE THE FOLLOWING INFORMATION AS ATTACHMENTS:
1.) Brief description and history of your business including legal structure, i.e. Partnership, Sole. 2.) Brief description of proposed collateral.
3.) Proposed term of repayment. 4.) 3-year business plan. 5.) Past 3-year tax returns of owner(s). 6.) Past 3-year tax returns of business. 7.)
Resume(s).
APPLICANT #1
I do not wish to furnish this information
(initials)_____
RACE/ □ American Indian/Alaskan Native □ White
NATIONAL □ Asian Pacific Islander □ Hispanic □ Black
ORIGIN □ Other___________________
MARITAL STATUS □ Married □ Separated □ Unmarried
SEX □ Female □ Male
APPLICANT #1 I do not wish to furnish this information
(initials)_____
RACE/ □ American Indian/Alaskan Native □ White
NATIONAL □ Asian Pacific Islander □ Hispanic □ Black
ORIGIN □ Other___________________
MARITAL STATUS □ Married □ Separated □ Unmarried
SEX □ Female □ Male
□ By Phone □ By Mail □ By Interview
Southeast Rural Community Assistance Project, Inc. 6
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P ROJECT, INC. S OUTHEAST R URAL C (County of Campbell)

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Completed 5 August 2020

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