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PERSONAL FINANCIAL STATEMENT Date:________________
Submitted to: HOMEBANK, 400 SOUTH MAIN, PALMYRA, MO 63461
Please read these directions before completing this application and check ( ) the appropriate box below
□ 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, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporations(s), complete Sections 1, 3, 4
and 5.
□ 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. Provide information in Section 2 about the person whose alimony, support, or maintenance payments or
income or assets you are relying on. Alimony, Child support, or separate maintenance income, need not be revealed if you do not wish to have it considered as a basis for
repaying this obligation.
□ If you are applying for joint credit with another person, please complete all sections, providing information in Section 2 about the joint applicant. You understand that the
bank will evaluate your combined assets in deciding whether to extend the requested credit and that you will be jointly liable if the requested credit is advanced.
W
E INTEND TO APPLY FOR JOINT CREDIT: ________________ _________________
A
PPLICANT CO- APPLICANT
SECTION 1 - Borrower Information
SECTION 2 - Co-Borrower Information
Name:
Name:
Residence Address:
Residence Address:
City, State & Zip:
City, State & Zip:
Length at Present Residence:
Length at Present Residence:
Date of Birth:
Date of Birth:
SSN:
SSN:
Position or Occupation:
Position or Occupation:
Business Name:
Business Name:
Business Address:
Business Address:
E-mail:
E-mail:
Business Phone: Residential Phone:
Business Phone: Residential Phone:
Length of Employment:
Length of Employment:
SECTION 3- Declarations
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 owned? If yes, please
provide details on a separate sheet(s).
Yes No
Are you a partner or officer in any other venture? If so,
describe:
Yes No
Are (either of) you a defendant in any suit or legal
action?
Yes No
Are you obligated to pay alimony, child support or
separate maintenance payments? If so, describe.
Yes No
Are any of (either of ) your assets held in a Trust?
Yes No
Personal bank accounts carried with what financial
institution?
Are (either of) you presently subject to any unsatisfied
judgments or tax liens?
Yes No
When, if ever have (either of ) you been audited by the
IRS?
Do (either of) you have a will? If so, name of executor
Yes No
Income tax settled through (date):
Are any assets pledged other than as described on
schedules? If so, describe.
Yes No
SECTION 4– Statement of Financial Condition
ASSETS
LIABILITIES
In Dollars
Cash on hand and in banks:
Notes payable to banks (secured):
Marketable Securities (see Schedule A):
Notes payable to banks (unsecured):
Non-Marketable Securities (see Schedule B):
Due to brokers:
IRA/Retirement Accounts:
Amounts payable to others (secured):
Restricted or control stocks:
Amounts payable to others (unsecured):
Partial interest in Real Estate (see Schedule C):
Unpaid income tax:
Real Estate Owned (see Schedule D):
Other unpaid taxes and interest:
Automobiles and other personal property:
Real estate mortgages payable (see Schedule D):
Cash value-life insurance (see Schedule E):
Other debts (itemize):
Other assets (itemize):
Total Liabilities
Net Worth
Total Assets
Total Liabilities & Net Worth
SECTION 5 - Sources of Income for Year ended:
Annual Income
Individual
Joint
Annual Expenditures
Individual
Joint
Contingent Liabilities
Individual
Joint
0.00
0.00
0.00
0.00
Salary, bonuses & commissions:
Mortgage/rental
Payments
Do you have any.. Yes No
Interest/Dividend Income:
Real Estate Taxes &
Assessments:
Contingent Liabilities
(endorser, co-maker,
guarantor?)
Real estate income:
Taxes- Federal, State
and Local
Leases or Contracts?
Other Income (List Source):
Insurance Payments
Involvement in pending legal
action?
Other Contract Payments
(Car, Charge Cards, etc)
Contested Income Tax Liens?
Alimony, Child Support,
Maintenance
Other Special Debt or
Circumstances
Other Expenses
Total Income
Total Expenditures
Total Contingent Liabilities
S
CHEDULE A - U.S. GOVERNMENTS & MARKETABLE SECURITIES
Number of Shares
or Face Value
(Bonds)
Description
In Name of
Are These
Pledged?
Market Value
S
CHEDULE B - NON-MARKETABLE SECURITIES
Number of
Shares
Description
In Name Of
Are These
Pledged?
Source of
Value
Value
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE
Address & Type of
Property
Title in
Name Of
% Of
Ownership
Date
Acquired
Cost
Market
Value
Mortgage
Maturity
Mortgage
Amount
S
CHEDULE D - REAL ESTATE OWNED
Address & Type
Of Property
Title in
Name Of
Date
Acquired
Cost
Market
Value
Mortgage
Maturity
Mortgage
Amount
S
CHEDULE E - LIFE INSURANCE CARRIED
Name of
Insurance Company
Owner of
Policy
Beneficiary
Face
Amount
Policy
Loans
Cash
Surrender
Value
S
CHEDULE F - BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED
Name & Address
of Lender
Credit in
The Name Of
Secured or
Unsecured
Original
Date
High
Credit
Current
Balance
(
USE ADDITIONAL SCHEDULES IF NECESSARY)
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 a change
is given to you by the undersigned. You are authorized to make all inquiries you deem necessary to verify the accuracy of the statements
made herein, and to determine my/our creditworthiness. You are authorized to answer questions about your credit experience with me/us.
Borrower:
Date:
Co-Borrower:
Date:
0.00
0.00
0.00
0.00
0.00
0.00
0.00%
0.00%
Revised: 03/2015 als
Credit Application and Borrower’s Certification
Type of Credit Requested-Check the appropriate boxes below and complete the applicable section.
□ secured □ individual credit – relying solely on my income or assets
□ unsecured □ individual credit – relying on my income or assets as well as
income or assets from other sources
□ joint credit – we intend to apply for joint credit
□ entity owners – the undersigned understand they may be asked
to co-sign or guarantee the loan being requested as they are the
owners, officers or control parties for the entity.
Amount Requested Payment Due Desired Proceeds of Credit to be used for
$______________ __________________ ____________________________
Loan Number _______________ Date of Application ________________
Above references are for lender’s use only and do not limit the applicability of this document to any particular loan or item.
CERTIFICATION
The undersigned hereby certifies the accuracy of all financial statements provided in connection with
this credit application and indicates that our financial condition has not materially changed by
signing below.
-------------------------------------------- Fold to Copy --------------------------------------------
AUTHORIZATIONS
1) (I/We) authorize the bank to perform any credit investigation necessary to verify
information supplied to us by the following means:
• By contacting banks or other credit sources disclosed to us to verify balance,
collateral and payment history.
• By requesting and obtaining a credit report from a third party Credit Reporting
Agencies.
• By contacting references provided.
2) (I/We) authorize the bank to report (my/our) names and information regarding this loan to
Credit Reporting Agencies.
3) (I/We) understand a copy of this authorization may be mailed or faxed to (my/our) creditors
as authorization to release information on (my/our) account directly to HOMEBANK and
any information received will be held strictly confidential and covered under the
HOMEBANK’s privacy policy.
4) In the event (my/our) loan is approved, (I/we) hereby authorize the HOMEBANK to request
payoff information directly from any creditor we intend to refinance with the proceeds.
Entity Name (if Applicable): _______________________________
___________________________________ _______________________________
Borrower Borrower
___________________________________ _______________________________
Borrower Borrower
____________________________________ ______________________________
Guarantor/Co-signer Guarantor/Co-signer
Fees to be Collected: $_________ Interest $_________Other Fees = __________ Total to be Collected
Rev 07/20/2020
FACTS
WHAT DOES HOMEBANK DO
WITH YOUR PERSONAL INFORMATION?
Why?
Financial companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you
how we collect, share, and protect your personal information. Please read this notice carefully
to understand what we do.
What?
The types of personal information we collect and share depend on the product or service you
have with us. This information can include:
◼ Social Security number and income
◼ Account balances and payment history
◼ Credit history and credit scores
When you are no longer our customer, we continue to share your information as described in
this notice.
How?
All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their
customers’ personal information; the reasons HOMEBANK chooses to share; and whether
you can limit this sharing.
Reasons we can share your personal information
Does HOMEBANK share?
Can you limit this
sharing?
For our everyday business purposes—
such as to process your transactions, maintain
your account(s), respond to court orders and legal
investigations, or report to credit bureaus
Yes
No
For our marketing purposes—
to offer our products and services to you
No
We don’t share
For joint marketing with other financial companies
No
We don’t share
For our affiliates’ everyday business purposes—
information about your transactions and experiences
No
We don’t share
For our affiliates’ everyday business purposes—
information about your creditworthiness
No
We don’t share
For our affiliates to market to you
No
We don’t share
For non-affiliates to market to you
No
We don’t share
Questions?
Call us at 573-769-2001 or Toll-Free at 1-855-577-2001 or
go to www.myhomebank.bank
Page 2
Who we are
Who is providing this notice?
HOMEBANK
What we do
How does HOMEBANK protect my
personal information?
To protect your personal information from unauthorized access
and use, we use security measures that comply with federal law.
These measures include computer safeguards and secured files
and buildings.
How does HOMEBANK collect my
personal information?
We collect your personal information, for example, when you
◼ Open an account or deposit money
◼ Pay your bills or apply for a loan
◼ Use your credit or debit card
We also collect your personal information from others, such as credit
bureaus.
Why can’t I limit all sharing?
Federal law gives you the right to limit only
◼ sharing for affiliates’ everyday business purposes—information
about your creditworthiness
◼ affiliates from using your information to market to you
◼ sharing for non-affiliates to market to you
State laws and individual companies may give you additional rights to
limit sharing.
Definitions
Affiliates
Companies related by common ownership or control. They can be
financial and nonfinancial companies.
◼ HOMEBANK does not share with our affiliates.
Non-affiliates
Companies not related by common ownership or control. They can be
financial and nonfinancial companies.
◼ HOMEBANK does not share with non-affiliates so they can market
to you.
Joint marketing
A formal agreement between nonaffiliated financial companies that
together market financial products or services to you.
◼ HOMEBANK does not jointly market.
400 S. Main
P.O. Box 311
Palmyra, Missouri 63461
573-769-2001
Fax 573-769-2345
IMPORTANT INFORMATION ABOUT THE PROCEDURES FOR OPENING A
NEW ACCOUNT
To help the government fight the funding of Terrorism and money laundering
activities, Federal law requires all financial institutions to obtain, verify, and record
information that identifies each person who opens an account.
What that means for you: When you open an account, we will ask for your name,
address, date of birth, and other information that will allow us to identify you. We will
also ask to copy your driver's license
Identification is for verification of identity only and will in no way be used in the loan
credit process
***Payment made by you in person, by mail or electronically Monday through Friday, will
be credited on the day we receive them.
***Payments received on Saturday will be credited on the next business day.
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Completed 15 December 2020

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