BANCRÉDITO INTERNATIONAL BANK, CORPORATION

CLEAR
BANCRÉDITO INTERNATIONAL BANK, CORPORATION
PERSONAL FINANCIAL STATEMENT
To: Bancrédito International Bank Corporation
Statement Date:
Individual - Provide financial information only about yourself
Joint - Provide financial information about yourself and other person
NAME
Date of Birth
NAME
Date of Birth
Relationship
Address
Home Phone No.
# Dependents
Bus. or Occ.
Bus. Phone #
NOTE: Every item in sections I and II must be completed for your loan request to be considered. Use “No” or “None” where necessary.
MIL
ASSETS
1
2
3
4
Cash On Hand and in Banks
Cash Value of Life Insurance
U.S. Gov. Securities
Other Marketable Securities
THO
SECTION I
LIABILITIES
HUN
21Notes Due to Banks
22 Notes Due to Others
23 Accounts & Bills Payable
24 Unpaid Income Taxes Due
Fed
25 Other Unpaid Taxes & Interest
Sec. II-A
Sec. II-B
Sec. II-C
Sec. II-C
Sec. II-
5 Notes & Accounts Receivable - Good
D
6 Other Assets Readily Convertible to Cash - Itemize
7
8
9
10 TOTAL CURRENT ASSETS
THO
HUN
Sec. II-A
Sec. II-G
Sec. II-G
State
26 Loans on Life Insurance Policies
Sec. II-B
27 Liens & Assessments Payable
28
29
30
31
32 TOTAL CURRENT LIABILITIES
11 Real Estate Owned
12 Mortgages & Contracts Owned
Sec. II-E
Sec. II-F
13 Notes & Accounts Receivable-Doubtful
Sec. IID
14 Other Securities-Not Readily Marketable Sec. IIC
15 Other Assets - Itemize
16
17
18
19
20 TOTAL ASSETS
33 Real Estate Mortgages Payable
E
34
Sec. II-
35
36
37
38 TOTAL LIABILITIES
39 NET WORTH (Total Assests minus Total Liab)
40 TOTAL LIABILITIES & NET WORTH
ANNUAL INCOME
Salary, Bonuses & Commissions
Dividends & Interest
Rental & Lease Income (Net)
Accts, Notes, Mtge. Receivable
MIL
ESTIMATE OF ANNUAL EXPENSES
$
$
$
$
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
Other Income - Itemize
$
Provide the following information only if Joint Credit is checked above
Other Person’s Salary, bonuses & Commissions
$
Income Taxes
Other Taxes
Insurance Premiums
Mortgage Payments
Rent Payable
$
$
$
$
Alimony/Child Support
Other Expenses
$
$
$
$
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.
Other Income of Other Person-Itemize
$
TOTAL
$
$
$
TOTAL
1
$
Rev. 10/10
BANCRÉDITO INTERNATIONAL BANK, CORPORATION
GENERAL INFORMATION
CONTINGENT LIABILITIES
Are any Assets Pledged? (See Section II)
Are you a Defendant in any Suits or Legal Actions?
Have you ever made a composition settlement with
creditors?
Have you ever been declared Bankrupt?
Explain:
No
No
No
Yes
Yes
Yes
As Endorser, Co-maker or Guarantor
On Leases or Contracts
Legal Claims
$
$
$
No
Yes
Federal - State Income Taxes
Other -
$
$
SECTION II
A. CASH IN BANKS AND NOTES DUE TO BANKS (List all Real Estate Loans in Section II-E)
NAME OF BANK
Type of Acc.
Type of Ownership
On Deposit
Notes Due Banks
COLLATERAL
(if any) & Type of Ownership
Cash on Hand
TOTALS
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
B. INSURANCE (List only those Policies that you own)
COMPANY
Face Amount
of Policy
$
LIFE:
Cash Surrender
Value
Policy Loan from
Insurance Co.
$
Other Loans Policy as
Collateral
$
$
$
$
BENEFICIARY
Malpractice or Product Liab.
TOTALS
C. SECURITIES OWNED (Including U.S. Gov’t Bonds and all other Stocks and Bonds
Face Value - Bonds
No. of Shares Stock
DESCRIPTION
Indicate those Not Registered in Your
Name
Type of
Ownership
COST
$
Market Value
U.S. Gov. Sec.
$
TOTALS
Market Value
Not Readily
M’ktable Sec.
Market Value
M’ktable Sec.
$
$
$
$
$
(Enter Sec. I Line 3)
(Enter Sec I Line 4)
(Enter Sec I Line 14)
Amount Pledged in
Secure Loans
$
D. NOTES AND ACCOUNTS RECEIVABLE (Money Payable or Owed to You Individually - Indicate by v If Others have an Ownership Interest)
MAKER/DEBTOR
v
When Due
Original
Amount
$
Monthly
Payment
$
Balance Due
Good Accounts
$
TOTALS
Balance Due
Doubtful Acc’ts
SECURITY
(If any)
$
$
$
(Enter Sec. I Line 5)
(Enter Sec. I Line 13)
2
Rev. 10/10
BANCRÉDITO INTERNATIONAL BANK, CORPORATION
E. REAL ESTATE OWNED
TITLE IN NAME OF
%
Own
Description &
Location
Date
Acqu
ired
Original
Cost
Present
Value of RE
Assessed
Value
$
$
$
$
TOTAL
TOTAL
(Enter Sec. I Line 11)
Mortgage or contract Payable
Bal. Due
$
Payment
Maturity
To Whom Payable
$
(Enter Sec. I Line 33)
F. MORTGAGES AND CONTRACTS OWNED
Cont.
Mtg.
%
Own
Maker
Name
Property
Covered
Address
Starting Date
Payment
$
Maturity
Balance Due
$
TOTAL
$
(enter Sec. I Line 12
G. NOTES (Other than Bank, Mortgage and Insurance Company Loans), ACCOUNTS, BILLS AND CONTRACTS PAYABLE
PAYABLE TO
Other Obligors
(if Any)
When Due
TOTALS
Notes Due “Others”
(Not Banks)
$
$
$
$
(Enter Sec. I Line 22)
Accounts & Bills
Payable
COLLATERAL (If Any)
(Enter Sec. I Line 23)
The above statements are submitted to Bancrédito International Bank, Corporation for the purpose of obtaining credit of maintaining credit on notes and bills bearing our signatures,
endorsements or guarantees and we agree to notify Bancrédito International Bank Corporation promptly of any change affecting our liability to pay. This is to further acknowledge
that Bancrédito International Bank Corporation has relied on the above statements in extending credit to the undersigned. We hereby certify that all matters set forth in the above
statements are true and correct and all assets, liabilities and contingent liabilities have been fully disclosed. Unless specifically noted, all assets are solely owned by the undersigned.
Under penalty for making false statements to an institution or overvaluing property to influence your action in granting or maintaing the credit, as aforesaid, the undersigned certify
that the information contained in this statement is correct.
You are authorized to make all inquires you deem necessary yo verify the accuracy of the statements made herein, and to determine my/our creditworthiness. The bank is authorized
to answer quiestions about its credit experience with me/us.
Date Signed
Signature
Date Signed
Signature
ID #
ID #
3
Rev. 10/10