Individual Financial Statement Form – Fill Out and Use This PDF

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© 2013 Wisconsin Bankers Association/Distributed by FIPCO®				INDIVIDUAL FINANCIAL STATEMENT
				IMPORTANT: Date and sign statement
				(For Wisconsin residents only)
				Date of Financial Statement
Name
Address
To						("Lender")

For the purpose of obtaining credit from Lender and any future credit granted by Lender, or to support the extension of credit already given, I make the

following statement to Lender of my financial condition on

. This statement is Lender's property.

NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under § 766.59, Wis. Stats., or court decree under

§766.70, Wis. Stats., adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted or an open-end credit plan is entered into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision.

INSTRUCTIONS FOR INFORMATION TO BE SUPPLIED BELOW:

Individual Credit. If a married applicant is applying for individual credit, complete this statement including all marital property and all individual property of the applicant, but do not include individual property of the non-applicant spouse. Include all liabilities of both spouses. Only the applicant must sign on page 2.

Joint Credit with spouse as joint applicant. If married applicants are applying for joint credit, include all assets and all liabilities of both spouses.

Both spouses must sign this statement.
Joint Credit with	as joint applicant who is not your spouse. If a married applicant is applying for

joint credit with someone other than his or her spouse, each applicant must complete a separate statement as if applying for individual credit, including all marital property and all individual property of the applicant. Do not include any individual property of the non-applicant spouse. Include all liabilities of the applicant and the applicant’s spouse. Only the applicant must sign on page 2.

For purposes of this statement:

Marital property means assets acquired with my or my spouse's income on or after 1-1-86; and

Individual property means property owned (whether in joint or sole name) by me prior to marriage, prior to establishing residence in Wisconsin, or prior to 1-1-86, however acquired, and property acquired by me by gift or inheritance at any time.

COMPLETE ALL BLANKS, WRITING "NO" OR "NONE" WHERE NECESSARY

ASSETS		LIABILITIES OF APPLICANT AND SPOUSE
Cash on Hand and in Financial Institutions (Schedule A)	$	Notes Payable - Lenders/Secured (Schedule E)	$
Gov't and Listed Securities (Schedule B)		Notes Payable - Lenders/Unsecured (Schedule E)
Unlisted Securities (Schedule B)		Notes Payable Others (Schedule E)
Notes and Loans Receivable (Schedule F)		Life Insurance Loans (Schedule C)
Homestead and Real Estate Owned (Schedule D)		Due to Brokers
Automobiles		Accounts Payable
Other Personal Property		Unpaid Income Taxes
Cash Value Life Insurance (Schedule C)		Real Estate Mortgage Payable (Schedule D)
Securities Held by Brokers in Margin Accts.		Real Estate Taxes
Equity in Partnership		Credit Cards
Equity in Proprietorship		Other Debts (Itemize Below)
Vested Pension Benefits or Profit Sharing
Other Assets: (Itemize Below)
		Total Liabilities
		Assets less Liabilities = Net Worth
TOTAL ASSETS	$	TOTAL LIABILITIES and NET WORTH	$
SOURCES OF INCOME FOR YEAR ENDED		CONTINGENT LIABILITIES OF APPLICANT AND SPOUSE
Salaries & Bonuses *	$	As Endorser, Co-Maker, or Guarantor	$
	$	On Lease or Contracts	$
Commissions	$	Legal Claims	$
Dividends & Interest	$	Other (describe)	$
Real Estate	$
Other **

*For Married Wisconsin residents, name each spouse and include the income of each spouse.

**Income from Alimony, Child Support or Separate Maintenance income and income from medical insurance, disability or wage continuation insurance need not be revealed if you do not wish the Lender to consider this income on determining your creditworthiness.

PERSONAL INFORMATION

Home Telephone		Social Security No.		Date of Birth
Employer(s) of Applicant(s)
Are any assets pledged or restricted other than indicated on the following schedules? If so, describe.
Are you a defendant in any legal actions or suits? If so, describe.
Are you a partner or officer in any other venture? If so, describe.
Do you have a will?	Yes	No If so, name of Personal Representative
Have you ever been declared Bankrupt? If so, describe.
Driver's License, (or if checked below, State ID Card) Name, No., State and Expiration Date:
State ID Card
State ID Card
Changed Name on Driver's License or State ID Card in Past 5 Years			No	Yes, and give Prior Name
			No	Yes, and give Prior Name

COMPLETE SCHEDULES AND SIGN ON PAGE 2

Page 1 of 2

Schedule A - Cash, Checking Accounts, Savings Accounts, & Certificates of Deposit

Schedule B - U.S. Government, Listed & Unlisted Securities (List on separate sheet if necessary)

*Indicates if Securities are Restricted By Contract or SEC Regulations.

Schedule C - Life Insurance Carried, Include Group

Schedule D - Real Estate Owned

Schedule E - Names of Lenders Where Credit Has Been Obtained

Schedule F - Notes and Loans Receivable

NOTICE: We may report information about your account to credit bureaus. Late payments, missed payments, or other defaults on your account may be reflected in your credit report.

I certify that this financial statement is true and complete. I authorize Lender or its agents to verify the information obtained in this statement and to obtain additional information concerning my financial condition, including, without limitation, consumer credit reports, although Lender may rely on this financial statement without any further verification. I authorize Lender to furnish such information and any other credit experiences with me to others and to answer any questions about my credit experience and other financial relationships with Lender, to the extent not prohibited by applicable law. I agree to notify Lender, in writing, of any change that materially affects the accuracy of this statement.

It may be a crime punishable by a fine or imprisonment or both to knowingly make false statements concerning any of the above information, under provisions of applicable federal and state law.

X

Applicant Signature

	(Date Signed)	X
		Joint Applicant Spouse Signature (joint credit only)
		For married Wisconsin resident. I understand Lender may be required by law
		to give notice of any credit transaction to my spouse. The credit applied for, if
		granted, will be incurred in the interest of my marriage or family.
		X
		Applicant Signature
		INDIVIDUAL FINANCIAL STATEMENT
WBA127.GPF Rev. 5/2013		Page 2 of 2