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[]
[]
["Personal Financial Statement"]
[]
[]
["Name:"]
["Occupation:"]
["Address:"]
[]
["For the purpose of obtaining loans and discounting paper with you, and otherwise procuring credit from time to time, I furnish you with the following statement and information, which is, and shown by my books to be a true and correct  "]
["statement of my financial condition on",null,null,".  I agree to and will notify you immediately in writing of "]
["any materially unfavorable change in my financial condition, and in the absence of such notice, or of a new and full written statement, this may be considered as a continuing statement and substantially correct; and it is hereby expressly agreed that upon application for further credit, this statement shall have the same force and effect as if delivered as an orginal statement of my financial condition at the time such further credit is requested."]
[]
["Note:  Please complete all blanks, writing \"NO\" or \"NONE\" where necessary"]
["Assets",null,null,"Liabilities"]
["Cash on hand and in bank",null,null,"Notes payable - ",0]
["Savings",null,null,"Notes payable - "]
["Certificates of deposit",null,null,"Notes payable -"]
["Accounts receivable",null,null,"Notes payable - "]
["Other (specify)",null,null,"Notes payable: Schedule 8",0]
["Other (specify)",null,null,"Accounts payable"]
["Total Current Assets",0,null,"Amounts payable relatives and friends"]
["Investments: Schedule 1",0,null,"Credit Cards: Schedule 9",0]
["Machinery and equipment: Schedule 2",0,null,"Mortgages residential real estate"]
["Furniture and fixtures: Schedule 3",0,null,"Mortgages on country real estate"]
["Vehicles: Schedule 4",0,null,"Other (specify): Schedule 10",0]
["Residential real estate: Schedule 5",0,null,"Other (specify): "]
["Country real estate: Schedule 6",0,null,"Other (specify): "]
["Cash value of life insurance",null,null,"Other (specify):  "]
["Other (specify): Schedule 7",0,null,"Other (specify):"]
["Other (specify):  ",null,null,"Other (specify):"]
["Other (specify): ",null,null,"Other (specify): "]
["Other (specify):  ",null,null,"Total Liabilities",0]
["Other (specify): ",null,null,"Net Worth",0]
["Total Assets",0,null,"Total Liabilities and Net Worth",0]
[]
["Other Financial Information:"]
["Salary and bonus for the year ended",null,null,0]
["Total income reported on most recent tax report",null,null,0]
["Taxes due, and unpaid",null,null,0]
["Total monthly payment: Schedule 11",null,null,0]
[]
["Personal:"]
[]
[]
[]
[]
["I, THE UNDERSIGNED, HEREBY CERTIFY AND DECLARE THAT THE ABOVE STATEMENT AND REPRESENTATIONS CONSTITUTE A TRUE AND ACCURATE ACCOUNT OF MY FINANCIAL CONDITION AS OF THE DATE GIVEN ABOVE. "]
[]
["Signature:",null,null,"Signature:"]
["Date:",null,null,"Date:"]

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["Add In List Sheet"]
[" These totals will be automatically placed into the the Financial Statement. "]
[]
[null,"Assets - Add In List"]
[]
[null,"Investments - Schedule 1",null,null,"Machinery and Equipment - Schedule 2"]
[null,"Description","Amount",null,"Description","Amount"]
[null,null,null," "]
[]
[]
[]
[]
[]
[null,"Total",0]
[]
[null,"Furniture and Fixtures - Schedule 3"]
[null,"Description","Amount"]
[]
[]
[]
[]
[]
[null,"Total",0,null,"Total",0]
[]
[null,"Other - Schedule 7",null,null,"Vehicles - Schedule 4"]
[null,"Description","Amount",null,"Description","Amount"]
[null," ",{"$nulls":4}," "]
[{"$nulls":4}," "," "]
[]
[]
[]
[]
[]
[null,"Total",0,null,"Total",0]
[]
[null,"Country real estate - Schedule 6",null,null,"Residential real estate - Schedule 5"]
[null,"Description","Amount",null,"Description","Amount"]
[]
[]
[]
[null,"Total",0,null,"Total",0]
[]
[null,"Liabilities - Add In List"]
[]
[null,"Notes Payable - Schedule 8",null,null,"Credit Cards - Schedule 9"]
[null,"Description","Amount",null,"Card Company - ","Amount"]
[]
[null," "]
[null," "]
[null," "]
[]
[]
[null,"Total",0,null,"Total",0]
[]
[null,"Other - Schedule 10",null,null,"Monthy Reoccurring Payments: Schedule 11"]
[null,"Description","Amount",null,"House"]
[{"$nulls":4},"Credit Cards"]
[{"$nulls":4},"Medical"]
[{"$nulls":4},"Other:  "]
[{"$nulls":4},"Other:  "]
[{"$nulls":4},"Other:  "]
[{"$nulls":4},"Other:  "]
[null,"Total",0,null,"Total Monthly Payments",0]