PERSONAL FINANCIAL STATEMENT

schedules may be completed jointly by married and unmarried applicants if theirThis statement and any applicableassets and liabilities are sufficiently joined so that the statement can be meaningfully and fairly presented on a combinedbasis; otherwise separate statements and schedules are required.

Single SeparatedMarriedApplicant is:Not completed jointlyCompleted jointly with spouseIf married, the financial statement is:

IndividualStatement of assets and liabilities as ofName and addressCo-Partnership

ICorporation(insert date, otherwise statement will be returned)

ASSETS LIABILITIES (Sch)Cash A $ Due to banks A $Stocks, bonds, etc. B $ Credit cards C $Accounts receivable TaxesC $$Notes receivable D $ Accounts payable C $Inventory E $ Notes payable D $Equipment F $ Due on equipment F $

Home G $ Due on real estate G $

Real estate G $ Other liabilities H $Personal property TOTAL LIABILITIES $$

Capital stock (if any)B $IRA $

Retained earnings $Total stockholders equity $

HOther Assets $

$NET WORTHTOTAL ASSETS $$

OTHER LIABILITIESSOURCES OF INCOME FOR YEAR ENDED

Salary, bonuses & commissions $

Dividends $

Real estate income $

Do you have any contingent liabilities? If so, describe:(Lawsuits, Indemnification, etc. )

As endorser, co-maker or guarantor? $

On leases or contracts? $

Legal claims (judgments, etc.) $

Other special debt $

Other income (Alimony, child support or separatemaintenance income need not be revealed if you donot wish to have it considered as a basis for bonding) $

$

$

Amount of contested income tax liensTOTAL $$

PERSONAL INFORMATION

Are you a defendant in any suits or legal actions?

Have you ever been declared bankrupt? If so, describe:

Are any assets pledged other than as described on schedU es?If so, describe:

Income tax settled through (date):

Personal bank accounts carried at:

Are any assets owned by a trust? Which?

If so, name of executor:Do you have a will?

Are you a partner or officer in any other venture? It so, describe:

Are you obligated to pay alimony, child support or separatemaintenance payments? If so, describe:

NEXT PAGE MUST BE COMPLETED

(Sch)

INSURANCE CARRIED

Fidelity Bonds on Officers & Employees

Life $ General Liability $

Property $ Other $

IF NOT SUFFICIENT SPACE, ATTACH SEPARATE SCHEDULESName and Location of Bank Account

NumberAmount of Deposit In Whose Name

Owed toBank

DateDueA

BANKDATA

Name of Security No.SharesPar

ValueMarketValue

In Whose NameRegistered

If Pledged, to Whomand for What PurposeB

STOCKSBONDS, ETC.

From Whom Due Amount DateDue To Whom Due AmountDateDue

From Whom Due Amount DateDue To Whom Due AmountDateDue

CACCOUNTS

RECEIVABLEAND

PAYABLE

DNOTES

RECEIVABLEAND

PAYABLE

Description Cost Price Market ValueEINVENTORY

Description Cost Price DepreciationCharged Off Book Value EncumbranceAmount

Payable MonthlyF

EQUIPMENT

Location and Description In Whose NameIs Title CostPresent Forced

Sale ValueAmount ofMortgage

Name ofMortgageeG

REAL ESTATE

Description of Other Assets Amount Description of Other Liabilities AmountHOTHER

ASSETS ANDLIABILITIES

Date Signed I

Signature Spouse's SignatureTitle

S.S. Number Date of BirthDate of Birth S.S. Number

The undersigned furnishes the foregoing as a true and accurate statement of the undersigned's financial condition as of the date given. _________________ may furnish copies of the foregoing statement and any information which it has now or may hereinafter obtain, for the purpose of securing bonds, reinsurance or co-insurance.

Married: Married2: Married3: Married5: Stocks: ar: nr: inv: equip: home: real estate: pp: ira: other2: ta: Due to Banks: credit cards: taxes: ap: np: due on equip: due on re: other liab: total liab: cap stock: ret earn: total equity: net worth: Salary2: Salary3: Salary4: Salary5: Salary6: Salary: Total:

Any Assets: defendant: Will: name of executor: bankrupt: partner or officer: assets pledged: income tax: alimony: bank account: fidelity bonds: life: property: gen liab: other:

name of bank:

Name of security: Name of security2: Name of security3: Name of security4: Fom Whom: From Whom 2: From Whom 3: From Whom 4: From Whom 5: From Whom 6: From Whom 7: From Whom8: Description: Description2: Description34: Description35: Description36: Description37: Description38: Location and Description: Location and Description2: Location and Description3: Location and Description4: Location and Description5: Account Number: No: Shares2: Shares3: Shares4: Shares1:

Account Number2: Account Number3: Amount2: Amount3: Amount4: Amount5: Amount6: Amount7: Amount8: Cost Price2: Cost Price3: Cost Price4: Cost Price5: Whose Name is Title: Whose Name is Title2: Whose Name is Title3: Whose Name is Title4: Whose Name is Title5: Date Due: Amount of Deposit: Amount of Deposit2: Amount of Deposit3: In Whose Name: In Whose Name2: In Whose Name3: Market Value2: Market Value3: Market Value4: Owed To Bank:

Date Due to Bank2: Date Due to Bank3: In Whose name Registerd: In Whose name Registerd2: In Whose name Registerd3: In Whose name Registerd4: To Whom Due: To Whom Due2: To Whom Due3: To Whom Due4: To Whom Due5: To Whom Due6: To Whom Due7: To Whom Due8: What Purpose: What Purpose2: What Purpose3: What Purpose4: Amount15: Amount16: Amount17: Amount18: Amount19: Amount20: Amount21: Amount22: Date Due to Bank: Date Due to Bank10: Date Due to Bank11: Date Due to Bank12: Date Due to Bank13: Date Due to Bank14: Date Due to Bank15: Date Due to Bank16: Date Due to Bank17: Des Charged off: Des Charged off2: Des Charged off3: Des Charged off4: Des Charged off5: Cost: Cost2: Cost3: Cost4: Cost5: Cost Price: Cost Price6: Cost Price7: Market Value:

Book Value2: Book Value3: Book Value4: Book Value5: Sale2: Sale3: Sale4: Sale5: Book Value: Encumbrance2: Encumbrance3: Encumbrance4: Encumbrance5: Encumbrance: Amount Payable Monthly: Amount Payable Monthly2: Amount Payable Monthly3: Amount Payable Monthly4: Amount Payable Monthly5: Sale: Amount of Morgage2: Amount of Morgage3: Amount of Morgage4: Amount of Morgage5: Amount of Morgage: Name of Mortagee: Name of Mortagee2: Name of Mortagee3: Name of Mortagee4: Name of Mortagee5: Description of other assets: Description of other assets2: Amount: Amount123: Amount1234: Description of other liab: Description of other liab2: Amountt: Amountt1: Day and month: Year: ss number: dob: dob2: Name and Address: day month: year: Corporation: Co-Partnership: Married4: Individual: any lawsuits: Title: Social Security Number: Date Due2: Date Due3: Date Due4: Date Due5: Date Due6: Date Due7: Date Due8: Cash: AgencyName: Agency NameAgencyAddress: AddressAgencyAddress2: AgencyPhone: Phone #AgencyFax: Fax #AgencyCode: Agency CodeAgencyAddressInput1: AgencyAddressInput2: AgencyPhoneInput: AgencyFaxInput: AgencyCodeInput: AgencyNameInput: