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Personal Financial Statement

FINANCIAL STATEMENT DATE
Today's date	Today's date:

INDIVIDUAL
Full Name
Date of Birth
Social Security Number

CONTACT INFORMATION
Street Address
City	State	Zip code
Home Phone	Business Phone	Cell

EMPLOYMENT
Position or Occupation
Length of Employment
Employer or Business Name
Employer or Business Address
Employer City	State	ZIP code
Income

ASSETS
Cash on hand and in bank	Ownership
Marketable Securities	Ownership
IRA / Retirement Accounts

SCHEDULE B: IRA, RETIREMENT ACCOUNTS & OTHER INVESTMENTS

Enter one item per line. Use Shift+Enter to add a new line.

REAL ESTATE OWNED

Enter one item per line. Use Shift+Enter to add a new line.

OTHER INFORMATION
Are you a guarantor, co-maker, or endorser for any debt not shown above? Applicant: Yes No	If yes, why?
Are you contingently liable for any lease or contract? Applicant: Yes No	If yes, why?
Are you party to any claim or lawsuit? Applicant: Yes No	If yes, why?
Are you presently subject to any unsatisfied judgment or tax liens? Applicant: Yes No	If yes, please explain
Are you a defendant in any legal action? Applicant: Yes No	If yes, why?
Are any of your taxes past due? Applicant: Yes No	If yes, why?
Are any tax returns being audited? Applicant: Yes No	If yes, why?
Have you or any firm in which you were an owner ever declared bankruptcy? Applicant: Yes No	If yes, why?

DISCLOSURES

The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of the undersigned. The undersigned acknowledge and understand that you are relying on the information provided therein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents, warrants and certifies that the information provide herein is true, correct and complete. Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse changes (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.

I/We authorize you to share this application, and any credit, employment or other information you may have obtained in connection with my/our application, with any of your affiliates and non-affiliates unless I/We initial here to indicate that I/We do not want you to share this application and related information with your affiliates and non-affiliates.

ECOA NOTICE

By signing below, you acknowledge and understand that should this new or extension of credit be denied, you have the right to a written statement of the specific reasons for denial. To obtain the statement , please contact us within 60 days from the date that you are notified of our decision. We will send you a written statement of the reason for denial within 30 days of your request. NOTICE: The Federal ECOA prohibits from discriminating against credit applicants based on race, color, religion, national origin, sex, marital status, age, because all of part of the applicant's income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers our compliance with this law is the Federal Deposit Insurance Corporation,

Consumer Response Center, 1100 Walnut St., Box 11 Kansas City, MO 64106

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Signed by Brian Potts
Signed On: January 7, 2026

Timestamp

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July 6, 2025 1:22 pm EDT

Personal Financial Statement Uploaded by Brian Potts - [email protected] IP 50.233.59.26