Fillable Trust Company Application (Arizona)

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Trust Company Application (Arizona)

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FI-LC-AP-TC-Trust_Company_Application 100 N. 15
th
Avenue, Suite 261, Phoenix, AZ 85007
Revised 02/05/2019
Trust Company Application
Personal Financial Statement
Section 7 Page 1 of 4
Do not use for business statement.
Legibly print or type all information.
There must be an answer provided for each question. Therefore, if not applicable use “None” or “N/A”.
Schedules, details and descriptions must be completed in space provided and by attachments if necessary.
Total Assets must equal Total Liabilities and Net Worth.
Describe any unusual assets or liabilities.
Name
Financial Condition As of Date
Address, City, State, Zip
Occupation
Customer at what financial institution
(office)
Assets
Amount
Liabilities
Amount
Cash in Bank
Notes Payable to Bank
Cash in other Banks (detail)
Notes payable to Other Banks (detail below)
Ordinary Accounts receivable - Good
Ordinary Accounts Payable
Due from Friends and Relatives (describe)
Due to Friends & Relatives (describe below)
Notes Receivable - Good (Sched 1)
Notes Payable to Others (describe below)
Mortgages Owned (Sched 1)
Readily Marketable Securities (Sched 4)
Automobile Loans or Leases
Other Securities (Sched 4)
Due to Brokers
Cash Surrender Value of Life Insurance (Sched 5)
Loans on Life Insurance (Sched 5)
Real Estate & Buildings (Sched 2)
Mortgages or Liens on Real Estate (Sched 3)
Automobiles
Installment Loans
Personal Property
Income Taxes Payable
Other Assets (describe below)
Other Taxes Payable
Other Liabilities (describe below)
Credit Cards
Total Assets
Total Liabilities
Net Worth (Assets Minus Liabilities)
Approximate Annual Income and Expense
(exclusive of ordinary living expenses)
Income
Amount
Fixed Expenses
Amount
Salary From
Insurance Premiums
Income from Securities
Rent or Mortgage Payments
Real Estate Rental
Income Taxes (for year
)
Net Income form Business or Profession
Other Taxes
Other (Alimony, child support or separate maint.)
Other (Include alimony, child support or
separate maintenance payments if you are
obligated to make them.
Total Income
Total
1.
Are the above evaluations on receivables conservative?
Yes
No (If no, explain by separate letter)
2.
Are any assets pledged or debts secured except as indicated?
Yes
No (If yes, itemize by debt and security)
3.
Do you have any contingent liabilities for guarantees, endorsements or otherwise?
Yes
No (If yes, explain)
4.
Do you do business with any other bank?
Yes
No (If yes, nature of business)
FI-LC-AP-TC-Trust_Company_Application 100 N. 15
th
Avenue, Suite 261, Phoenix, AZ 85007
Revised 02/05/2019
Trust Company Application
Personal Financial Statement
Section 7
Page 2 of 4
5.
If you are married are any of the above assets your spouse’s separate property?
Yes
No (If yes, itemize)
6.
Are there any suits, judgments, tax deficiencies or other claims
pending or in prospect against you?
Yes
No (If yes, explain by separate letter)
7.
Have you ever gone through bankruptcy or compromised a debt?
Yes
No (If yes, explain by separate letter)
8.
Have you made a will?
Yes
No
Who is named executor of estate?
Complete the following schedules
Schedule 1 - Notes and Mortgages Owned
Describe here or on separate sheet any important or unusual receivables.
Name Of Debtor
Amount Due
How Payable
Remarks (Include description & value of any security)
Schedule 2 – Real Estate and Buildings
Provide details of encumbrances on Schedule 3 opposite proper parcel number.
Parcel
Location &Description
(Include improvements)
Monthly
Income
Title In
Name Of
Value
On Land
Improvements
Encumbrances
Amount
Fire Ins.
Amount
No. #1
No. #2
No. #3
No. #4
No. #5
What is the basis for the above valuations? (State whether cost, fair market value today, or other basis)
Are there any properties held on joint tenancy?
Yes
No
Parcel numbers:
Schedule 3 - Real Estate Encumbrances
Parcel
Amt. Owing
Per Sched 2
Nature of Encumbrance and to Whom
Payable
Interest
Rate
Due
Date
Payment
Amount
*Are Interest & Principal
Current.
No. #1
Yes
No
No. #2
Yes
No
No. #3
Yes
No
No. #4
Yes
No
No. #5
Yes
No
* If any payments of principal or interest are delinquent, provide details.
Are any taxes delinquent?
Yes
No (If yes, give amount and details)
Are there any unrecorded deeds, liens, or other claims not shown above?
FI-LC-AP-TC-Trust_Company_Application 100 N. 15
th
Avenue, Suite 261, Phoenix, AZ 85007
Revised 02/05/20
Trust Company Application
Personal Financial Statement
Section 7
Page 3 of 4
Schedule 4 - Securities Owned
Attach separate schedule sheet if needed.
Stock - Shares,
Bond Amounts
Description
Value Carried
On This
Statement
Current Market
On Listed Amount
Estimated Value on
Unlisted
Annual
Dividend
@
Amount
@
Amount
In whose name are the above securities held?
If in names of yourself and co-owner, are they joint tenancy?
Schedule 5 - Insurance
Public liability on autos $
Property damage on autos $
Life Insurance
Beneficiary
Amount Of Policy
Cash Value
Amount Of Liens
Net Cash Value
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$ $ $ $
Trust Company Application
Personal Financial Statement
Section 7 Page 4 of 4
Personal Financial StatementPersonal Financial Statement
State whether you have within the last 15 years:
a. been convicted of any criminal offense other than traffic violation? Yes No
b. had a final judgment entered against him/her in a civil action on account of fraud, misrepresentation, or
deceit? Yes No
c. filed bankruptcy? Yes No
d. had an order entered against you by an administrative agency of this state, the federal government, or any
other state or territory of the United States involving fraud, misrepresentation, or deceit? Yes No
If you answered yes to any of the aforementioned (9 a, b, c, or d), furnish complete details on a separate sheet.
I certify that the above information provided by me is true, complete and correct to the best of my knowledge
and belief.
__________________ ____________________________
Date Signature
FI-LC-AP-TC-Trust_Company_Application 100 N. 15th Avenue, Suite 261, Phoenix, AZ 85007 Revised 02/05/2019
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Trust Company Application (Arizona)

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Completed 20 July 2020

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