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A young couple holding a debit or credit card and shopping online.
Personal Financial Statement Form
Step
1
of
7
14%
As of (date)
(Required)
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Applicant Name
(Required)
First
Last
Social Security Number
(Required)
Birthdate
(Required)
Month
Month
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Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
(Required)
Work Phone
(Required)
Email
(Required)
Co-Applicant
Check the box if you have a co-applicant
Co-Applicant Name
First
Last
Co-Applicant Social Security Number
Birthdate
Month
Month
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Day
Day
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30
31
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Year
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2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1981
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1924
1923
1922
1921
1920
Sources of Income
Salary
(Required)
Salary (Co-applicant)
Bonus and Commissions
(Required)
Bonus and Commissions (Co-applicant)
Dividends
Dividends (Co-applicant)
Real Estate Income
(Required)
Real Estate Income (Co-applicant)
Other Income: Itemize*
Income Name
Amount
Actions
Edit
Delete
There are no
Entries.
Add Entry
Maximum number of entries reached.
Other Income: Itemize (Co-applicant)*
Income Name
Amount
Actions
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There are no
Entries.
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Maximum number of entries reached.
Total Income
(Required)
Total Income (Co-applicant)
* Alimony, child support or separate maintenance payments need not be disclosed unless relied upon as a basis for extension of credit. If disclosed, payments received under
court order
written agreement
oral understanding
General Information
Employer
Positions or Profession
Number of Years
Employer's Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer's Phone
Partner, officer or owner in any other venture?
Yes
No
if so, explain:
Are any assets pledged?
Yes
No
if so, explain:
Income taxes settled through (Date)
Month
Month
1
2
3
4
5
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7
8
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10
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12
Day
Day
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2
3
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24
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29
30
31
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Are you a defendant in any suits or legal action?
Yes
No
if so, explain:
Have you ever taken bankruptcy?
(Required)
Yes
No
if so, explain:
Do you have a will?
Yes
No
With whom?
Do you have a trust?
Yes
No
With whom?
Number of dependents
Ages
Contingent Liabilities
As an endorser, co-maker or guarantor
On leases
Legal Claims
Provision for federal income taxes
Other special debt, e.g., recourse or repurchase liability
Contingent Liabilities Total
Schedule A
Schedule A from Members Exchange Credit Union
Name of Institution
Name on Account
Balance on Deposit
High Credit
Amount Owing
Monthly Payment
Secured by What Assets
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Schedule A from other Credit Unions, Brokers, Savings & Loan Association, Finance Companies or Banks
Name of Institution
Name on Account
Balance on Deposit
High Credit
Amount Owing
Monthly Payment
Secured by What Assets
Actions
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Entries.
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Schedule B
Schedule B US Government Securities
Description of Securities
In Name Of
Market Value
Pledged
Actions
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Entries.
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Schedule B Listed Securities
Description of Securities
In Name Of
Market Value
Pledged
Actions
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Entries.
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Schedule B Unlisted Securities
Description of Securities
In Name Of
Market Value
Pledged
Actions
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Entries.
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Schedule B Other Equity Interests
Description of Securities
In Name Of
Market Value
Pledged
Actions
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Entries.
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Schedule C
Schedule C Real Estate Owned (and related debt, if applicable)
Description of Property or Address
Title in Name Of
Date Acq.
Cost + Improvements
Present Mkt. Value
Bal. Owing
Mo. Payt.
Holder
Actions
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Entries.
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Schedule D
Schedule D Real Estate Mortgages & Land Contracts Receivable (and related debt, if applicable)
Description of Property or Address
Title in Name Of
Date Acq.
Balance Receivable
Monthly Payment
Bal. Owing
Mo. Payt.
Holder
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Entries.
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Schedule E
Schedule E Life Insurance Carried
Name of Company
Face Amount
Cash Surrender Value
Loans
Beneficiary
Actions
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Entries.
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Maximum number of entries reached.
Total Assets
Assets
Members Exchange Account - See Schedule A
Cash on hand and in Institutions - See Schedule A
US Government Securities - See Schedule B
Listed Securities - See Schedule B
Unlisted Securities - See Schedule B
Other Equity Assets - See Schedule B
Accounts and Notes Receivable
Real Estate Owned - See Schedule C
Mortgages and Land Contracts Receivable - See Schedule D
Cash Value Life Insurance - See Schedule E
Other Assets: Itemize
Asset Name
Amount
Actions
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Entries.
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Maximum number of entries reached.
Total Assets
Total Liabilities
Liabilities and Net Worth
Notes Payable - This CU - See Schedule A
Notes Payable - Other Institutions - See Schedule A
Notes Payable - Relatives
Notes Payable - Others
Unpaid Taxes
Real Estate Mortgages Payable - See Schedule C
Real Estate Mortgages Payable - See Schedule D
Life Insurance Loans - See Schedule E
Other Liabilities: Itemize
Asset Name
Amount
Actions
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There are no
Entries.
Add Entry
Maximum number of entries reached.
Total Liabilities
Net Worth
Total Liabilities and Net Worth
Misc.
In order to expedite this application and serve you better, it may be necessary for us and/or our agents to contact your accountant and/or insurance agent for additional personal or business information. Please indicate below your authorization by checking the boxes and providing the contact information.
Accountant/CPA Name
Accountant/CPA Phone
Insurance Agency Name
Insurance Agency Phone