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PERSONAL FINANCIAL STATEMENT

SUSQUEHANNA BANCSHARES, INC.

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 only Sections 1 and 3.

If you are applying for joint credit with another person, complete all Sections providing information in Section 2 about the joint application.

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 a basis for repayment of the credit requested, complete all Sections, providing information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying.

If this statement relates to your guaranty of the indebtedness of other person(s), firm(s) or corporation(s), complete Sections 1 and 3.

SECTION 1 – INDIVIDUAL INFORMATION (Type or Print)		SECTION 2 – OTHER PARTY INFORMATION (Type or Print)
Name			Name

Residence Address			Residence Address

City, State & Zip			City, State & Zip

Position or Occupation			Position or Occupation

Business Name			Business Name

Business Address			Business Address

City, State & Zip			City, State & Zip

Home Phone No.	Business Phone No.		Home Phone No.	Business Phone No.

SECTION 3 – STATEMENT OF FINANCIAL CONDITION AS OF _			_________________, 20

ASSETS	Individual	Joint	If Joint,	LIABILITIES	Individual	Joint	If Joint,
(Excluding Assets of doubtful value)	(In Dollars)	(In Dollars)	with whom		(In Dollars)	(In Dollars)	with whom

Cash on Hand & in Banks	$	$	Notes Payable to Banks – Secured	$	$

Marketable Securities – Sch A	$	$	Notes Payable to Banks – Unsecured	$	$

Non-Marketable Securities – Sch B	$	$	Due to Brokers	$	$

Broker Held Securities - Margin Accts	$	$	Items Payable to Others – Secured	$	$

Restricted or Control Stocks	$	$	Items Payable to Others – Unsecured	$	$

Interest in Real Estate Equities – Sch C	$	$	Accounts and Bills Due	$	$

Real Estate Owned – Sch D	$	$	Unpaid Income Tax	$	$

Loans Receivable	$	$	Other Unpaid Taxes and Interest	$	$

Automobiles/Other Personal Property	$	$	Real Estate Mortgages – Sch D	$	$

Cash Value Life Insurance – Sch E	$	$	Other Debts – Itemize:	$	$

Other Assets – Itemize:	$	$		$	$

Retirement Accounts	$	$		$	$

	$	$		$	$

	$	$	TOTAL LIABILITIES	$	$

	$	$	NET WORTH	$	$

TOTAL ASSETS	$	$	TOTAL LIABILITIES AND	$	$
			NET WORTH

					PERSONAL INFORMATION
SOURCES OF INCOME FOR YEAR ENDED	___________, 20				PERSONAL INFORMATION
SOURCES OF INCOME FOR YEAR ENDED	___________, 20

Salary, Bonuses, & Commissions		$	Do you have a will?		If yes, name of executor:
Salary, Bonuses, & Commissions

Dividends		$	Yes	No
Dividends

Real Estate Income		$	Are you a partner or officer in any other venture? If so, describe:
Real Estate Income

Other Income (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)
		$	Are you obligated to pay alimony, child support or separate maintenance payments? If so, describe:

		$

	TOTAL	$	Are any assets pledged other than as described on schedules? If so, describe:
	TOTAL

CONTINGENT LIABILITIES
Do you have any contingent liabilities? If so, describe:			Income tax settled through (date):

As Endorser, Co-Maker, or Guarantor?		$	Are you a defendant in any suits or legal actions?
As Endorser, Co-Maker, or Guarantor?

On Leases or Contracts?		$
On Leases or Contracts?

Legal Claims		$	Personal bank accounts carried at:
Legal Claims

Other Special Debt		$
Other Special Debt

Amount of Contested Income Tax Liens		$	Have you ever been declared bankrupt? If so, describe:
Amount of Contested Income Tax Liens

(COMPLETE SCHEDULES AND SIGN ON NEXT PAGE)

(USE ADDITIONAL SCHEDULES IF NECESSARY)

SCHEDULE A – U.S. GOVERNMENTS & MARKETABLE SECURITIES

Number of Shares or	Description	In Name of	Are These	Market Value
Face Value (Bonds)	Description	In Name of	Pledged?	Market Value
Face Value (Bonds)			Pledged?
				$

				$

				$

				$

SCHEDULE B – NON-MARKETABLE SECURITIES

Number of

Description	In Name of	Are These	Source of Value	Value
Description	In Name of	Pledged?	Source of Value	Value
		Pledged?
				$
				$
				$
				$

SCHEDULE C – PARTIAL INTERESTS IN REAL ESTATE EQUITIES

Address & Type of Property	Title in Name of	% of	Date		Cost	Market Value	Mortgage	Mortgage
Address & Type of Property	Title in Name of	Ownership	Acquired		Cost	Market Value	Maturity	Amount
		Ownership	Acquired				Maturity	Amount
		%		$		$		$
		%

		%		$		$		$

		%		$		$		$

		%		$		$		$

SCHEDULE D – REAL ESTATE OWNED

Address & Type of Property	Title in Name of	Date		Cost	Market Value	Mortgage	Mortgage	Monthly
Address & Type of Property	Title in Name of	Acquired		Cost	Market Value	Maturity	Amount	Payment
		Acquired				Maturity	Amount	Payment
			$		$		$	$

			$		$		$	$

			$		$		$	$

			$		$		$	$

SCHEDULE E – LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP INSURANCE

Name of Insurance Company	Owner of Policy	Beneficiary	Face Amount	Policy Loans	Cash Surrender
Name of Insurance Company	Owner of Policy	Beneficiary	Face Amount	Policy Loans	Value
					Value
			$		$

			$		$

			$		$

			$		$

SCHEDULE F – BANKS OR FINANCE COMPANIES WHERE CREDIT HAD BEEN OBTAINED

Name & Address of Lender	Credit in the Name of	Secured or	Original Date	High Credit	Current Balance
Name & Address of Lender	Credit in the Name of	Unsecured?	Original Date	High Credit	Current Balance
		Unsecured?
				$	$

				$	$

				$	$

				$	$

Please submit this completed form to your Susquehanna lending representative.

The 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. I shall annually supply an updated financial statement. The personal financial statement and any other financial or other information that I give you shall be your property. You are authorized to make all inquiries you deem necessary to verify the accuracy of the statements made herein, and to determine my/our credit-worthiness. You are authorized to answer questions about your credit experience with me/us.


	Signature (Individual)
	SS. No. ___________________________	Date of Birth
	Signature (Other Party)
Date Signed _______________, 20	SS. No. ___________________________	Date of Birth

Question	Answer
Form Name	Susquehanna Personal Financial Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	PersonalFinanci alStatement td loan application pdf personal form

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