personal financial statement - Vortex Financial

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PERSONAL FINANCIAL STATEMENT. Prepared on ... Notes Payable To Banks - Unsecured ... SOURCES OF INCOME FOR YEAR ENDED ______200.
PERSONAL FINANCIAL STATEMENT Prepared on _______________

|SECTION 1 - INDIVIDUAL INFORMATION |SECTION 2 - OTHER PARTY INFORMATION | |Name | |Name | | |Residence | |Residence | | |Address | |Address | | |City, | |City, | | |State, Zip| |State, Zip| | |Position | |Position | | |or | |or | | |Occupation| |Occupation| | |Business | |Business | | |Name | |Name | | |Business | |Business | | |Address | |Address | | |City, | |City, | | |State, Zip| |State, Zip| | |Residenc| |Business| |Residenc| |Business| | |e Phone | |Phone | |e Phone | |Phone | |

|SECTION 3 - STATEMENT OF FINANCIAL CONDITION AS OF ___________________________, 200 | |Cash | |Notes Payable To Banks - | | | | |Secured | | |Marketable Securities - | |Notes Payable To Banks - | | |Schedule A | |Unsecured | | |Non-Marketable Securities - | |Notes Payable To Others - | | |Schedule B | |Secured | | |Real Estate Equities - | |Notes Payable To Others - | | |Schedule C | |Unsecured | | |Real Estate Owned - Schedule | |Accounts And Bills Due | | |D | | | | |Loans Receivable - Secured | |Income Tax Due | | |Loans Receivable - Unsecured | |Other Taxes Due | | |Automobiles Owned/Financed | |Real Estate Mortgages Due - | | | | |Schedule D | | |Other Personal Property | |Other Debts | | |Cash Value - Life Insurance -| | | | |Schedule E | | | | |Other Assets | | | | | | |Total Liabilities |$ | | | |Net Worth |$ | |Total Assets |$ |Total Liabilities And Net |$ | | | |Worth | |

|SOURCES OF INCOME FOR YEAR ENDED ______200|PERSONAL INFORMATION | |Salary, Bonus & | |Do you have a will? | |Commissions | | | |Dividends | | | |Real Estate Income | |Are you a partner or officer in any other | | | |venture? If yes, describe. | |Other Income | | | | | |Are you obligated to pay alimony, child | | | |support or separate maintenance payments? | | | |If yes, describe. | | | | | | | |Are any assets pledged other than as | | | |described on schedules? If yes, | | | |describe. | |Total |$ | | |CONTINGENT LIABILITIES |Income tax settled through (date) | | |_______________ | |Do you have any contingent liabilities? If|Are you a defendant in any suits or legal | |so, describe.. |actions? If yes, describe. | |As endorser, co-maker| |Have you ever filed for bankruptcy? If | |or guarantor? | |yes, describe. | |On leases or | | | |contracts? | | | |Legal claims? | |Personal bank accounts carried at: | |Other debts? | | | |Contested income tax | | | |liens? | | | | |$ | |

PERSONAL FINANCIAL STATEMENT - PAGE 2 OF 2

|SCHEDULE A - MARKETABLE SECURITIES | | | | | | |

|SCHEDULE B - NON-MARKETABLE SECURITIES | | | | |

|SCHEDULE C - INTERESTS IN REAL ESTATE EQUITIES | | | | |

|SCHEDULE D - REAL ESTATE OWNED | | | | |

|SCHEDULE E - LIFE INSURANCE | | | | |

|SCHEDULE F - BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED | | | | | | |

The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor. Each undersigned understands that you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and complete and that you may consider this statement as continuing to be true and correct until a written notice of a change is given to you by the undersigned. You are authorized to make all inquires you deem necessary to verity the accuracy of the statement made herein, and to determine my/our creditworthiness. You are authorized to answer questions about your credit experience with me/us.

|Date signed |Date signed | |Signature (individual) |Signature (other party) | |Print Name |Print Name | |Social Security number |Social Security number | |Date of Birth |Date of Birth | |Driver's license |Driver's license |

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