ASSETS LIABILITIES AND NET WORTH

FINANCIAL STATEMENT FOR A STOCKMAN OR FARMER
Loan Officer: __________________________________
NMLS# :______________________________________
NMLS# 419846
Name
Address
The following statement and information are furnished by the undersigned for the purpose of obtaining credit from this bank from time to time.
This statement represents my true financial conditions on
notice of any change is given to you by the undersigned.
Applicant is applying for this loan:
.
Individually
You may consider this statement as continuing to be true and correct until written
Jointly
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, complete all applicable sections.
Check
Appropriate
Box
Purpose of Loan
If this is an application for joint credit with another person, complete applicant and co-applicant sections and indicate or provide explanation relating
to any assets owned jointly or by a trust or liabilities owed with others. (Attach schedules and explanatory notes if necessary.)
We intend to apply for joint credit.
Applicant
Co-Applicant
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 the basis for repayment of the credit requested, complete all sections to the extent possible, providing information in the
application section about the person on whose alimony, support, or maintenance payments or income or assets you are relying. (Attach schedules
and explanatory notes if necessary.)
Loan Amount Requested
NOTE: COMPLETE ALL BLANKS, WRITING "NO" OR "NONE" WHEN NECESSARY.
ASSETS
LIABILITIES AND NET WORTH
CURRENT LIABILITIES
(DUE IN 12 MONTHS OR LESS)
CURRENT ASSETS
Cash on hand and in banks (including checking and saving
accounts and certificates of deposit)
Accounts payable
$
$
Short term notes payable (Sch. 9)
Government Bonds and Securities
Unsecured notes payable to banks (Sch. 6)
Other investments
Taxes payable
Farm products, grain and feed on hand (Sch. 1)
Current Portion- Intermediate
Livestock for resale (Sch. 3)
Equipment (Sch.8)
ASCS Payments Receivable
Livestock (Sch. 7)
All other current assets
Current Portion - Long term
Farm real estate (Sch. 10)
Other real estate (Sch. 11)
Accrued intermediate interest
TOTAL CURRENT ASSETS $
0
Accrued long term interest
Farm Machinery (Sch. 2)
INTERMEDIATE LIABILITIES
(DUE IN 1 TO 7 YEARS)
Notes payable (mach., equip.) (Sch. 8)
Automobiles
0
TOTAL CURRENT LIABILITIES $
INTERMEDIATE ASSETS
Less current portion listed above
0
0
0
0
0
0
Notes Receivable
Notes Payable Livestock (Sch. 7)
Personal Property
Breeding Livestock
Less Current Portion listed above
All other intermediate assets
Unsecured Notes Payable to Banks (Sch. 6)
Less Current Portion listed above
TOTAL INTERMEDIATE ASSETS $
0
0
TOTAL INTERMEDIATE $
LONG TERM ASSETS
LONG TERM LIABILITIES
Farm real estate (Sch. 4)
Farm real estate (Sch. 10)
Other real estate (Sch. 5)
0
0
0
0
TOTAL LONG TERM LIABILITIES $
0
Less current portion listed above
All other long term assets
Other real estate (Sch. 11)
Less current portion listed above
TOTAL LONG TERM ASSETS $
TOTAL ASSETS $
0
0
TOTAL LIABILITIES $
0
TOTAL $
0
SCHEDULE 1 - FARM PRODUCTS, FEED, AND GRAIN ON HAND
CROP
QUANTITY
WHERE STORED
PRICE/UNIT
TOTAL VALUE
0
TOTAL
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SCHEDULE 2 - FARM MACHINERY AND AUTOMOTIVE EQUIPMENT
DESCRIPTION
MAKE
QUANTITY
PURCHASED
DATE
TOTAL
COST
PRESENT
VALUE
0
0
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SCHEDULE 3 - LIVESTOCK
NUMBER
OF HEAD
BREED
SEX
AVERAGE
WEIGHT
PER
VALUE
PER CWT
TOTAL
VALUE
TOTAL
LEGAL DESCRIPTION
(SHOW COUNTY AND STATE)
ACRES
SCHEDULE 4 - FARM AND RANCH LANDS
NATURE OF IMPROVEMENTS
VALUE PER ACRE
TOTAL MARKET
VALUE
0
MORTGAGE HOLDER
0
TOTAL
SCHEDULE 5 - OTHER REAL ESTATE
LEGAL DESCRIPTION
(SHOW COUNTY & STATE)
TYPE OF REAL ESTATE
NATURE OF
IMPROVEMENTS
MORTGAGE HOLDER
MARKET VALUE
0
TOTAL
SCHEDULE 6 - UNSECURED NOTES PAYABLE TO BANKS
NAME OF BANK
ORIGINAL
AMOUNT
PURPOSE OF LOAN
AMOUNT
OWED
0
CURRENT
DUE
WHEN DUE
0
-
SCHEDULE 7 - LOAN SECURED BY LIVESTOCK
LENDER
TYPE
SECURITY
# OF HEAD
TOTAL
AMOUNT OWED
WHEN DUE
0
CURRENT DUE
0
SCHEDULE 8 - LOANS ON FARM MACHINERY AND AUTOMOTIVE EQUIPMENT
LENDER
DESCRIPTION
AMOUNT OWED
TOTAL
0
WHEN DUE
CURRENT
0
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SCHEDULE 9 - SHORT-TERM NOTES PAYABLE
NAME OF LENDER
PURPOSE OF LOAN
ORIGINAL
AMOUNT
AMOUNT
OWED
WHEN
DUE
CURRENT DUE
0
TOTAL
0
SCHEDULE 10 - LIENS ON FARM AND RANCH LANDS
NAME OF LENDER
ACREAGE AND LOCATION
ORIGINAL AMOUNT
AMOUNT
0
TOTAL
OWED
CURRENT DUE
0
0
SCHEDULE 11 - LIENS ON OTHER REAL ESTATE
NAME OF LENDER
ACREAGE AND LOCATION
ORIGINAL AMOUNT
TOTAL
AMOUNT
0
OWED
CURRENT DUE
0
0
SCHEDULE 12 - LIFE INSURANCE CARRIED INCLUDING M.S.L.I. & GROUP INS.
NAME OF INSURANCE COMPANY
OWNER OF
POLICY
BENEFICIARY
FACE
AMOUNT
POLICY
LOANS
CASH SURRENDER VALUE
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.
Alimony, child support, separate maintenance received under
Court Order
Written Agreement
Oral Understanding
PERSONAL INFORMATION
PLEASE USE SEPARATE SHEET FOR ADDITIONAL DETAILS
Is any income likely to be reduced prior to loan being paid off
Yes (Explain),
No
Are you a partner or officer in any other venture? If so, describe.
Are you obligated to pay alimony, child support or separate maintenance payments?
If so, describe:
Are any assets pledged other than as described on schedules?
If so, describe:
Income tax settled through (date)
CONTINGENT LIABILITIES
Are you a defendant in any suits or legal actions? (Yes or No)
Personal bank accounts carried at: __________________________________________________________
Do you have any contingent liabilities? If so, describe.
As endorser, co-maker or guarantor?
Savings Account Number: _________________________________________________________________
On leases or contracts?
Checking Account Number:
Have you ever been declared bankrupt in the last 10 years? (Yes or No)
Legal Claims?
If yes, explain: ____________________________________________________________________________
_______________________________________________________________________________________
Year? _________________
Other Special Debt.
Amount of contested tax liens.
This year I will lease
irrigated acres
I have resided at present location
years
dryland acres
pasture acres
months. Formerly resided
I CERTIFY THAT THE STATEMENT ON THE REVERSE SIDE AND THE SCHEDULES AND INFORMATION ABOVE ARE CORRECT.
DATED ON THIS
, 20
DAY OF
Complete only if making application for credit to be used primarily for agricultural purposes, a secured loan, joint, credit, or if you reside in a community property state.
Age
Married
Unmarried
Separated
This information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others, execute a guaranty in your favor. Each undersigned
understands that you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or continue credit. Each undersigned represents and warrants that the information provided is true and complete and that you may consider this statement as
continuing to be true and correct, until a written notice of a change is given to you by the undersigned. You are authorized to make all inquiries you deem necessary to verify that the accuracy of the statements made herein, and to determine my/our creditworthiness. You are authorized to answer question
about you credit experience with me/us.
Right to Receive Copy of Appraisal: We may order an appraisal to determine the property’s value and charge you for this appraisal. We will promptly give you a copy
of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.
Signature (Individual)
SSN
DOB
DL#
Date
Signature (Individual)
SSN
DOB
DL#
Date
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(11/13)
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