First Citizens Financial Statement – Fill Out and Use

INTERNAL USE ONLY

Branch _______________________________________

Associate ____________________________________

Please mail or fax completed and signed form along with an Application to:

First Citizens Bank – Working Capital Finance • P.O. Box 4715 • Greensboro, NC 27404 • Toll Free Tel: (866) 214-2476 / Fax (336) 292-3725

PERSONAL INFORMATION (Please Print)

Check this box if you are providing a current year’s income tax return complete with all schedules in lieu of completing the below section, “Annual Income”. By doing so, you certify that the tax return information is correct and that First Citizens Bank may rely upon it as stated below. Note: The annual Expenditures and Contingent Liabilities Sections must still be completed.

ANNUAL INCOME AND EXPENDITURES FOR YEAR ENDED:

STATEMENT OF FINANCIAL CONDITIONS AS OF (Date):

NAME ___________________________________________________

SCHEDULE A - Cash, Checking and Savings Accounts, Certificates of Deposit, Money Market Funds, Etc.

SCHEDULE B & C - U.S. Government & Marketable Securities or Non-Marketable Securities (Please Indicate if Non-Marketable) (Use Additional Sheet if Necessary)

SCHEDULE D - Personal Residence & Real Estate Investments, Mortgage Debt (Attach Additional Schedule if Necessary) *Including Taxes and Insurance

SCHEDULE E - Life Insurance Carried, Including Group Insurance

SCHEDULE F - Business Ventures (Use Additional Sheets if Necessary)

SCHEDULE G - Loans Owing Banks, Broker, Finance Companies, and Others (Mastercard, Visa, Etc.)

If yes for any of the above, give detail: (Use additional sheets if necessary)

This financial statement is given to First Citizens Bank (the “Bank”) by the person(s) signing this statement in connection with an application for credit or extension of credit to such person(s) or to another based upon the guarantee of such person(s). Every person signing this statement agrees that the Bank is entitled to rely upon the information in this statement in its credit decision relating to such person or to another based upon the guarantee of such person.

Every person who signs this financial statement certifies and agrees that (1) the information provided in this statement is true and complete and gives an accurate description of such person’s financial condition; except as listed on this statement, (2) such person has no undisclosed direct or contingent liabilities; and (3) title to all listed assets is solely in the name of such person and no other person or entity has an interest in such assets, unless otherwise listed in this statement. In the event of any change in such person’s name, address, or employment, such person agrees to send written notice to the Bank within five (5) business days after such change. Every person who signs this statement further agrees to send written notice to the Bank within five (5) business days after the occurrence of any material and adverse change (A) in any of the information contained in this statement, or (B) in the ability of such person to perform his or her obligations which are owed to the Bank or (C) in the financial condition of such person. If no such written notice is given, the Bank shall be authorized to consider this statement as a continuing statement, substantially correct in all respects.

The Bank if hereby authorized to request a consumer report on any person signing this statement in connection with the present application for credit or any update, renewal, or extension of such credit. Upon request, the Bank will tell any such person whether or not a consumer report was requested and if requested, the name and address of the consumer reporting agency that furnished the report. Every person signing this statement further authorizes the Bank to make all necessary inquiries to verify the information in this statement and also authorizes all such persons or entities the Bank contacts to completely respond to such inquiries.