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. If you are not applying with a co-applicant, please leave the Co-Applicant section blank. All fields marked with an asterisk (*) are required.

Financial Statement

Are you applying as an individual or with a co-applicant? *

For Wisconsin residents only:

If legally separated:

Notice to Married Applicants: No provision of any marital property agreement, unilateral statement under § 766.59, Wis. Stats., or court decree under § 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 credit plan is entered into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision.





How would you prefer to be contacted? *

Housing Status

What is your housing status? *


Are you employed? *

If employed, please fill out the information about applicant employer below.

If you have a co-applicant, please complete the co-applicant section.


Total Asset Values

Total Values

Other Accounts



Liability Totals

Income Taxes Payable

Other Taxes Payable

Charge Cards Payable (Schedule 4)

Installment Loans (Schedule 4)

Loans on Life Insurance

Real Estate Debt (Schedule 3)

Loans on Stocks & Bonds

Other Liabilities

Liability & Asset Totals

Liability & Asset Totals

Total Value

Annual Income

Annual Income

Annual Total

Other Income

Annual Expenses

Annual Expenses Totals

Other Expenses Annual Totals

Contingent Liabilities

Contingent Liabilities

Other Contingent Liabilities

General Information

General Information

If you are co-applying, these questions apply to both you and your spouse.

Are any assets held in Trust? *

Are any assets pledged or debts secured except as shown? *

Have you ever had a repossession? *

Have you ever had a bankruptcy or had a judgment against you? *

Have you ever been a principal or guarantor of a firm that declared bankruptcy? *

Are you a party to any claim or lawsuit? *

Has there been an IRS audit in the past 3 years? *

If there has been an IRS audit in the past 3 years, has the audit been settled?

Schedule 1: Marketable Securities

Marketable Securities

Are any of the securities restricted?

Do you own 10% or more of the outstanding stock of any company?

Marketable Security One

Marketable Security Two

Marketable Security Three

Schedule 2: Notes Receivable - Mortgage & Deed of Trust Owned

Mortgages & Deeds Owned

Mortgage & Deed of Trust Owned One

Mortgage & Deed of Trust Owned Two

Mortgage & Deed of Trust Owned Three

Schedule 3: Real Estate Holdings - Mortgages or Liens

Mortgages or Liens on Real Estate Holdings

Mortgage or Lien One

Mortgage or Lien Two

Mortgage or Lien Three

Schedule 4: Credit Cards And Loans Payable

Credit Card or Loan Payable


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.