Individual Financial Statement Form – Fill Out and Use This PDF

Enter the Date of Financial Statement, the date of your financial condition in the statement you make 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.

Enter the Name and the Address, and write To the Lender ("Lender").

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 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.

For Wisconsin residents only: mark legally separated, unmarried or married, and write the Name of spouse and the Address.

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.

Complete all blanks, writing "NO" or "NONE" where necessary.

Under ASSETS, enter Cash on Hand and in Financial Institutions (Schedule A), Gov't and Listed Securities (Schedule B), Unlisted Securities (Schedule B), Notes and Loans Receivable (Schedule F) and Homestead and Real Estate Owned (Schedule D). Enter Automobiles, Other Personal Property, Cash Value Life Insurance (Schedule C), Securities Held by Brokers in Margin Accts., Equity in Partnership, Equity in Proprietorship and Vested Pension Benefits or Profit Sharing, and itemize Other Assets.

Under LIABILITIES OF APPLICANT AND SPOUSE, enter Notes Payable - Lenders/Secured (Schedule E), Notes Payable - Lenders/Unsecured (Schedule E), Notes Payable Others (Schedule E), Life Insurance Loans (Schedule C), Due to Brokers, Accounts Payable, Unpaid Income Taxes, Real Estate Mortgage Payable (Schedule D), Real Estate Taxes and Credit Cards, and itemize Other Debts.

Enter TOTAL ASSETS, Total Liabilities, and Assets less Liabilities = Net Worth, then TOTAL LIABILITIES and NET WORTH.

Under SOURCES OF INCOME FOR YEAR ENDED, enter Salaries & Bonuses*, Commissions, Interest, Dividends & Real Estate and Other**. The * after Salaries & Bonuses: for Married Wisconsin residents, name each spouse and include the income of each spouse. The ** after Other: 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.

Under CONTINGENT LIABILITIES OF APPLICANT AND SPOUSE, enter As Endorser, Co-Maker, or Guarantor, On Lease or Contracts, for Legal Claims and for Other (describe).

Under PERSONAL INFORMATION, enter Date of Birth, Social Security No., Home Telephone and 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 or No. If so, name of Personal Representative. Have you ever been declared Bankrupt? If so, describe. Driver's License, (or if checked, State ID Card) Name, No., State and Expiration Date: State ID Card. Changed Name on Driver's License or State ID Card in Past 5 Years: Yes, and give Prior Name, or No.

Complete schedules and sign on page 2.

In Schedule A - Cash, Checking Accounts, Savings Accounts, & Certificates of Deposit, enter the Type, Name of Financial Institution, Amount and In Name Of, and mark PLEDGED NO or YES.

In Schedule B - U.S. Government, Listed & Unlisted Securities (List on separate sheet if necessary), enter the Face Value (Of Bonds) or No. of Shares, Description*, Owner and Market Value, and mark PLEDGED NO or YES. The * after Description indicates if Securities are Restricted By Contract or SEC Regulations.

In Schedule C - Life Insurance Carried, Include Group, enter the Face Amount, Company Name, Owner, Beneficiary, SURRENDER CASH Value and Loans.

In Schedule D - Real Estate Owned, enter the Property Address & Type of Owner, Date Acquired, Cost, Value Mkt., MORTGAGE Amount, $ Monthly, Maturity and Insurance.

In Schedule E - Names of Lenders Where Credit Has Been Obtained, enter the Lender Name & Address, Date Made, Date Due, Credit High, Current Balance, Monthly Payment, Borrower, and mark Sec. or Unsec.

In Schedule F - Notes and Loans Receivable, enter the Unpaid Amount, Name of Maker, Date Made and Pledged Security.

By signing you 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 this information, under provisions of applicable federal and state law.

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.