Personal Financial Statement

Instructions: Please review this entire form before beginning. You may need to enter data not immediately available. Once the form has been sent, you will not be able to go back and make corrections. We suggest printing your completed from before sending. All fields marked with an asterisk (*) are required.

Financial Statement






Amount In Dollars
Cash - Checking Accounts
Cash - Savings Accounts
College Fund 529
Securities - Stocks/Bonds/Mutual Funds
Notes & Contracts Receivable
Life Insurance (Cash Surrender Value)
Personal Property (Autos, Jewelry, etc)
Retirement Funds (IRAs, 401ks, etc)
Real Estate (Market Value)
Other Assets (Please Specify)
Total Assess (Total of All Assets Above)


Amount In Dollars
Current Debt (Credit Cards, Accounts)
Notes Payable (Describe Below)
Taxes Payable
Real Estate Mortgages (Describe Below)
Other Liabilities (Specify)
Total Liabilities (Total of All Liabilities Above)

Net Worth

Amount In Dollars
Net Worth (Total Assets minus Total Liabilities)



Notes and Contracts Held

From Who Owing Balance Owing
Total Notes and Contracts Held

Securities: Stocks/Bonds/Mutual Funds

Name of Security Market Value
Total Securities

Stock in Privately Held Companies

Company Name Estimated Market Value
Total Stocks

Real Estate

Description/Location Amount Owing Market Value
Total Real Estate

Credit Card & Charge Card Debit

Name of Card/Creditor Amount Due
Total Credit Card Debt

Notes Payable (Excluding Monthly Bills)

Name of Creditor Amount Owing
Total Notes Payable

Mortgage/Real Estate Loans Payable

Name of Creditor Amount Owing
Total Mortgages


Endorsement and Signatures

I certify that all information provided by me herein, including attachments (s) is true, correct and complete. I authorize Farmers Savings Bank to make whatever inquiries about me you deem necessary and appropriate for the purpose of evaluating my credit, including obtaining credit reports and contacting my employer. I also authorize Farmers Savings Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies. I agree to provide any further information the Bank might require to process my application.