Personal Financial Statement Form

Step 1 of 7

As of (date)(Required)

Applicant Name(Required)

First Last

Social Security Number(Required)

Birthdate(Required)

Address(Required)

Street Address Address Line 2 City 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

Income Name	Amount	Actions

There are no Entries.

Income Name	Amount	Actions

There are no Entries.

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	Actions

There are no Entries.

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

There are no Entries.

Schedule B

Schedule B US Government Securities

Description of Securities	In Name Of	Market Value	Pledged	Actions

There are no Entries.

Schedule B Listed Securities

Description of Securities	In Name Of	Market Value	Pledged	Actions

There are no Entries.

Schedule B Unlisted Securities

Description of Securities	In Name Of	Market Value	Pledged	Actions

There are no Entries.

Schedule B Other Equity Interests

Description of Securities	In Name Of	Market Value	Pledged	Actions

There are no Entries.

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

There are no Entries.

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	Actions

There are no Entries.

Schedule E

Schedule E Life Insurance Carried

Name of Company	Face Amount	Cash Surrender Value	Loans	Beneficiary	Actions

There are no Entries.

Total Assets

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