Instructions on the Completion of a Personal Financial Statement
Tab 1:
Instructions on how to complete the Personal Financial Statement (PFS)
Tab 2:
First (1st) page of a
sample
PFS
Tab 3:
Second (2nd) page of
sample
PFS
Tab 4:
First (1st) page of PFS to be completed by Borrower
Tab 5:
Second (2nd) page of PFS to be completed by Borrower
1. Complete the second page (TAB 5) first and then fill in the totals from each schedule on page one (TAB 4)
where it indicates.
2. Only list those assets and liabilities that are legally titled in your individual name (listed in section 1) or
jointly with the Other Party (listed in section 2).
3. If you own real estate or business assets or have debts that are owned by another entity (ex. limited
liability company, limited partnership, corporation etc.) list the equity you have in these entities under
"Business Ventures" in the Assets column.
4. Under "Cash Surrender Value-Life Insurance" in the asset column only include the net cash surrender
value of the policy (i.e. the amount the insurance company would pay you if you canceled the policy) rather
than the death benefit payable to your beneficiary. The death benefit would be listed in Schedule E under
"Face Amount".
5. If you have any questions on how to complete the PFS or would like assistance preparing it, please contact
any of our business bankers. Contact information for our business bankers can be found at
S
A
M P
L
E
Submitted to: Date:10/01/20xz
Res. Phone: 888-112-2323 Bus. Phone: 888-222-4343 Res. Phone:
Yes No Yes No Yes No In dollars (omit cents) (individual)
(joint) If joint with whom In dollars (omit cents) (individual) $30,000.00 $30,000.00 $150,000.00 $0.00 $100,000.00 $0.00 $0.00 $1,000.00 $0.00 $0.00 $225,000.00 $0.00 $0.00 $0.00 $30,000.00 $74,000.00 $85,000.00 $50,000.00 $0.00 $30,000.00 $105,000.00 595,000.00 $ 700,000.00
$ $ - $ - Total Liabilities and Net Worth $700,000.00
(Individual) (joint) (Individual) (joint) (Individual) (joint)
$14,000.00 $3,600.00 $5,000.00 $2,200.00 $6,000.00 $8,800.00 $19,000.00 $0.00 $6,600.00 $0.00 $0.00 $0.00 $5,000.00 44,000.00
$ $ - $ 26,200.00 $
-$ $ -Total Contingent Liabilities
Any estimated capital gains tax on the unrealized asset appreciation? Other special debt or circumstances?
If "yes" to any question(s) describe:
Do you have any… Yes No
Contingent liabilities (as endorser, co-maker or guarantor?) (On leases? On contracts? Involvement in pending legal actions?
Contested income tax liens?
Total Income Other income (alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)
Annual Expenditures Mortgage/rental payments Real estate taxes & assessments Taxes-federal, state & local Insurance payments Other contract payments
(car payments, charge cards, etc.) Alimony, child support, maintenance
Other expenses Total Expenditures Salary, bonuses & commissions
Dividends & Interest Real estate income
-$ Section 4 - Annual Income For Year End
Annual Income Contingent Liabilities Estimated Amounts
-$ Total Assets
Total Liabilities Net Worth
Real estate mortgages payable - see Schedules D & H
Amounts payable to others - secured Amounts payable to others - unsecured Accounts & bills due
Unpaid income tax Other unpaid taxes & interest Real estate owned - see Schedule D
Accounts, loans & notes receivable Securities held by broker in margin accounts
Restricted, control or margin account stocks
Automobiles
Cash surrender value - life insurance - see Schedule E
Vested interest in deferred compensation/ profit-sharing plans - See schedule F
Length of employment:
Assets
(Do not include assets of doubtful value)
If joint with whom (joint)
Liabilities
Notes payable to banks & others - see Schedule H
Due to brokers Cash, Checking & Savings, CD's -
see Schedule A
U.S. Gov't & marketable securities - see Schedule B
City, State & Zip: Altoona, PA 16602
Social Security #: 123-456-7891
Date of Birth: 01/01/19xz
Position or occupation: Dry Cleaning
Business Name: Dry Supply, Inc.
Business Address: 1212 Red Street
Non-marketable securities - see Schedule C
Are (either of) you a defendant in any suit or legal action?
Are (either of) you presently subject to any unsatisfied judgements to tax liens?
Business Address: City, State & Zip: Date of Birth: Position or occupation: Business Name: City, State & Zip: Social Security #:
Bus. Phone: Length at present address:
Business ventures - see Schedule G Other assets/personal property itemize - see Schedule G if applicable
Reliance Bank
PERSONAL FINANCIAL STATEMENT
IMPORTANT: Read these directions before completing this Statement
If you are applying for individual credit in your own name and are relying on your own income, or assets and not the income or assets of another person as the basis for repayment of the credit requested, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporation(s), complete only Sections 1, 3, and 4.
If you are applying for individual credit but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as a basis for repayment of the credit requested, complete all Sections. Provide information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying on. Alimony, child support, or separate maintenance income, need not be revealed if you do not wish to have it considered as a basis for replaying this obligation.
Section 1 - Individual Information (type or print)
Name: Jane Smith
Address: 1122 Blue Street
Section 2 - Other Party Information (type or print)
Name: Address:
City, State & Zip: Altoona, PA 16601
Length at present address: 14 years
Length of employment: 20 years
When, if ever, have (either of) you been audited by IRS? Section 3 - Statement of Financial Condition as of
Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than the amounts owed? If yes, please provide details on a separate sheet.
(J)
(J) % Owned
By You
100% 100%
% Vested
Years in Business
(J) Due
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 acknowledges and understands that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents, warrants, and certifies that (1) the information provided herein is true, correct and complete and gives a correct and complete showing of the financial condition of the undersigned, (2) the undersigned has no liabilities direct, indirect or contingent except as set forth in this statement, and (3) legal and equitable title to all assets listed herein is in the undersigned's sole name, except as may be herein otherwise noted. 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 change (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 and the undersigned hereby authorizes all persons of whom you make such inquiries to respond thereto in full. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.
10/1/2015 Signature (individual) Jane Smith
Date signed
Chase 10,000 200 Credit Card-Revolving
First Commonwealth Bank 40,000 20,000 1,000 2015 Ford Fusion
SCHEDULE H - LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (MASTERCARD, VISA, ETC.) Owing to (Acct. No.) Date of Original
Borrowing/Amount Present Balance Monthly Payment Maturity Date Secured By SCHEDULE G - BUSINESS VENTURES (Use additional sheet if necessary)
List Name and Address of Any Business Venture In Which You Are a Principal or Partner
Your Position/Title in
the Business Line of Business
Total Assets Listed in Section
3
Your % of Ownership Net Worth of Business
Present Net Value of Your Investment
$50,000
SCHEDULE F - VESTED INTEREST IN DEFERRED COMPENSATION/PROFIT-SHARING PLANS Company Name Account Number Manner of Payout
(Annuity, Lump Sum, etc.) Type: 401K, 403B,Pension, IRA Beneficiary Amount
Prudential Jane Smith Joe Smith-Husband $200,000 0 $85,000
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance Company Owner of Policy Beneficiary and Relationship Face Amount Policy Loans Cash Surrender Value
Prudential 401k Joe Smith
Reliance Bank
Florida Condo 19x9 75,000 50,000 550 2020 Bank of America
1122 Blue Street, Altoona, PA 19x3 150,000 24,000 300 2020
1,000 shares Dry Supply, Inc. Jane Smith Registered 100,000 Book Value
SCHEDULE D - INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary) Description/Location of
Real Estate Investment
Date of Original Investment/Amount
Market Value of Your % of Investment
Present Balance Monthly Payment
Mortgage Maturity Date
Mortgage Owed To SCHEDULE C - NON-MARKETABLE SECURITIES (Use additional sheet if necessary)
Description
Number of Shares In Name of Are these Registered, Pledged, or Held
by Others? Market Value Method of Valuation
1,500 shares Giant Public CO. Jane Smith Registered 150,000 NYSE
PNC Savings Jane Smith NA 20,000
Number of Shares or
Face Value of Bonds Description In Name of
Are these Registered, Pledged, or Held
by Others? Market Value Exchanges Where Traded SCHEDULE B - U.S.GOVERNMENT & MARKETABLE SECURITIES (use additional sheet if necessary)
SCHEDULE A - CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.
Name of Financial Institution Type of Account Owner If Pledged, to Whom? Balance
Submitted to: Date:
Res. Phone: Bus. Phone: Res. Phone:
Yes No
Yes No
Yes No
In dollars (omit cents) (individual)
(joint) If joint with whom
In dollars (omit cents) (individual)
-$
-$ $ - $ - Total Liabilities and Net Worth $0.00
(Individual) (joint) (Individual) (joint) (Individual) (joint)
-$ $ - $
-$ $ -If you are applying for individual credit in your own name and are relying on your own income, or assets and not the income or assets of another person as the basis for repayment of the credit requested, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporation(s), complete only Sections 1, 3, and 4.
If you are applying for individual credit but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as a basis for repayment of the credit requested, complete all Sections. Provide information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying on. Alimony, child support, or separate maintenance income, need not be revealed if you do not wish to have it considered as a basis for replaying this obligation.
City, State & Zip: City, State & Zip:
Social Security #: Social Security #:
Section 1 - Individual Information (type or print) Section 2 - Other Party Information (type or print)
Name: Name:
Address: Address:
Business Address: Business Address:
City, State & Zip: City, State & Zip:
Date of Birth: Date of Birth:
Position or occupation: Position or occupation:
Business Name: Business Name:
Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than the amounts owed? If yes, please provide details on a separate sheet.
Are (either of) you a defendant in any suit or legal action?
Are (either of) you presently subject to any unsatisfied judgements to tax liens?
Length at present address: Length at present address:
Length of employment: Length of employment:
Bus. Phone:
Cash, Checking & Savings, CD's - see Schedule A
Notes payable to banks & others - see Schedule H
U.S. Gov't & marketable securities -
see Schedule B Due to brokers
When, if ever, have (either of) you been audited by IRS? Section 3 - Statement of Financial Condition as of Assets
(Do not include assets of doubtful value)
Liabilities
(joint) If joint with whom
Restricted, control or margin account stocks Accounts & bills due
Real estate owned - see Schedule D Unpaid income tax
Non-marketable securities -
see Schedule C Amounts payable to others - secured
Securities held by broker
in margin accounts Amounts payable to others - unsecured
Cash surrender value - life insurance - see Schedule E
Vested interest in deferred compensation/ profit-sharing plans - See schedule F
Accounts, loans & notes receivable Other unpaid taxes & interest
Automobiles
Real estate mortgages payable - see Schedules D & H
Total Liabilities Net Worth
Business ventures - see Schedule G Other assets/personal property itemize - see Schedule G if applicable
Salary, bonuses & commissions Mortgage/rental payments Do you have any… Yes No Dividends & Interest Real estate taxes & assessments
Contingent liabilities (as endorser, co-maker or guarantor?)
Total Assets $ - $ -Section 4 - Annual Income For Year End
Annual Income Annual Expenditures Contingent Liabilities Estimated Amounts
Total Contingent Liabilities Other expenses
Other special debt or circumstances?
Total Income Total Expenditures If "yes" to any question(s) describe:
Real estate income Taxes-federal, state & local (On leases? On contracts?
Other income (alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)
Insurance payments Involvement in pending legalactions?
Other contract payments
(car payments, charge cards, etc.) Contested income tax liens? Alimony, child support,
maintenance
Any estimated capital gains tax on the unrealized asset appreciation?
(J)
(J) % Owned
By You
% Vested
Years in Business
(J) Due
SCHEDULE A - CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.
Name of Financial Institution Type of Account Owner If Pledged, to Whom? Balance
Number of Shares or
Face Value of Bonds Description In Name of
Are these Registered, Pledged, or Held
by Others? Market Value Exchanges Where Traded SCHEDULE B - U.S.GOVERNMENT & MARKETABLE SECURITIES (use additional sheet if necessary)
SCHEDULE C - NON-MARKETABLE SECURITIES (Use additional sheet if necessary)
Number of Shares Description In Name of Are these Registered, Pledged, or Held
by Others? Market Value Method of Valuation
SCHEDULE D - INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary) Description/Location of
Real Estate Investment
Date of Original Investment/Amount
Market Value of Your
% of Investment Present Balance Monthly Payment
Mortgage Maturity Date
Mortgage Owed To
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance Company Owner of Policy Beneficiary and Relationship Face Amount Policy Loans Cash Surrender Value
SCHEDULE F - VESTED INTEREST IN DEFERRED COMPENSATION/PROFIT-SHARING PLANS Company Name Account Number Manner of Payout
(Annuity, Lump Sum, etc.) Type: 401k, 403B, Pension, IRA Beneficiary Amount
SCHEDULE G - BUSINESS VENTURES (Use additional sheet if necessary) List Name and Address of Any
Business Venture In Which You Are a Principal or Partner
Your Position/Title in
the Business Line of Business
Total Assets Listed in
Section 3 Your % of Ownership
Net Worth of Business
Present Net Value of Your Investment
SCHEDULE H - LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (MASTERCARD, VISA, ETC.) Owing to (Acct. No.) Date of Original
Borrowing/Amount Present Balance Monthly Payment Maturity Date Secured By
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 acknowledges and understands that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents, warrants, and certifies that (1) the information provided herein is true, correct and complete and gives a correct and complete showing of the financial condition of the undersigned, (2) the undersigned has no liabilities direct, indirect or contingent except as set forth in this statement, and (3) legal and equitable title to all assets listed herein is in the undersigned's sole name, except as may be herein otherwise noted. 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 change (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 and the undersigned hereby authorizes all persons of whom you make such inquiries to respond thereto in full. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned.