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["Town & Country Bank"]
["Personal Financial Statement"]
["Name(s):"]
["Individual, or Joint Statement:",{"$nulls":9},"Page 1 of 2"]
["Statement of Financial Condition as of:",{"$nulls":9},"P:\\finstmt\\Blank Personal Balance Sheet.xls"]
["Current Assets",{"$nulls":4},"Current Liabilities"]
["Type of Account or Asset",null,null,null,"Value or Balance","Current Notes due to Banks and Others"]
["Cash and Checking balances",{"$nulls":4},"Owed To","Lien On",null,"Rate","Payment","Balance"]
["Savings Balances"]
["Certificates of Deposit "]
["Marketable Bonds & Securities"]
["Contracts and Notes Receivable (current)",{"$nulls":4},"Credit Cards/Personal Accounts",null,null,null,"Payment","Balance"]
["Other Assets Readily Convertible to Cash"]
[]
[]
[{"$nulls":5},"Unpaid Income Taxes Due"]
[{"$nulls":5},"Loans against Cash Value of Life Insurance "]
["Total Current Assets",null,null,null,0,"Total Current Liabilties",{"$nulls":4},0]
["Titled Vehicles, Trucks & Trailers",{"$nulls":4},"Loans against Vehicles"]
["Year","Make","Model",null,"Value","Owed To","Lien On",null,"Rate","Payment","Balance"]
[]
[]
[]
[]
[null,null,null,"Total Vehicles",0,"Vehicle Leases"]
["Mortgages and non-current contract owned",{"$nulls":4},"Owed To","Vehicle",null,null,"Payment"]
["Investments not readily marketable"]
["Retirement accounts (itemize)"]
["Cash Value of Life Insurance",{"$nulls":4},"Other Personal Loans"]
["Other Personal Property",{"$nulls":4},"Owed To","Lien On",null,"Rate","Payment","Balance"]
[]
[]
["Real Estate Owned",{"$nulls":4},"Real Estate Loans"]
["Description/Address",null,null,null,"Value","Owed To","Lien On",null,"Rate","Payment","Balance"]
[]
[]
[]
[]
[null,null,null,"Total Real Estate",0,"Other Payments"]
["Investments in Closely Held Businesses",{"$nulls":4},"Type","Paid to","Pmt Frequency",null,"Amount"]
["Description",null,null,null,"Value","Rent"]
[{"$nulls":5},"Child Sup."]
[]
[]
[null,null,null,"Total Business Investments",0,"Total Payments & Liabilities",null,null,null,0,0]
["Total Assets",null,null,null,0,"Net Worth",{"$nulls":4},0]
["     I/we certify this information and all supporting documents provided to Town & Country Bank (Bank) is true, correct and complete to the best of my/our knowledge,"]
["and understand all lending decisions will be based on the Bank's independent analysis of the information.  I/we hereby authorize the release to Town & Country Bank all"]
["pertinent information about my/our accounts, including information from our accountant, other creditors and other parties with pertinent information.  I/we authorize"]
["the Bank to check my/our credit and employment history, and/or to have a credit reporting agency prepare a credit report on me/us.  All said information will be held in "]
["strictest confidence by Town & Country Bank.",null,null,"We intend to apply for joint credit _______    _______ (initials)."]
[]
[]
["___________________________________",null,null,null,"__________","_______________________________________",{"$nulls":4},"__________"]
["Signature",null,null,null,"Date","Signature",{"$nulls":4},"Date"]

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["Name(s): ",0,null,null,null,"Page 2 of 2"]
["Statement of Financial Condition as of: ",null,"00:00:00"]
[]
["Life Insurance Information"]
["Company","Policy #","Policy owner","Face amount","Cash value","Loan Value"]
[]
[]
[]
[]
["Liability, Property, Auto and other Casualty Insurance Information"]
["Type of Insurance","Company",null,"Agent",null,"Coverage"]
[]
[]
[]
[]
["Rental Agreements"]
["Leasor",null,"Property","Lease terms",null,"Written contract?"]
[]
[]
[]
[]
[]
["Marketable Bonds, Mutual Funds, Stocks and other Securities"]
["Description","Where held",null,"Cash or margin","Cost value","Market Value"]
[]
[]
[]
[]
[]
["Contracts and Notes Receivable"]
["From whom",null,"Description","Payment amount","Maturity Date","Balance "]
[]
[]
[]
[]
[]
["Income Summary and Other Information"]
["Note:  Alimony, child support or separate maintenance income need",null,null,"Income Information",null,"Annual amount"]
["not be revealed if you do not wish to have it considered.",null,null,"Salary, bonuses & commissions"]
["Your Tax ID Number ",null,null,"Joint maker's salary, if applicable"]
["Joint maker's Tax ID Number",null,null,"Dividend and interest income"]
["Address:",null,null,"Rental and lease income"]
[null,null,null,"Other Income"]
["Telephone Number(s)",null,null,"Total Annual Income",null,0]
["Please answer the following questions. If \"Yes\" is indicated for questions 1 to 5, please explain on an attached sheet."]
[{"$nulls":5},"Yes or No"]
["1. Have you been declared bankrupt in the past 10 years?"]
["2. Are there any unsatisfied judgments against you?"]
["3. Are you a party to a lawsuit at this time?"]
["4. Are you obligated to pay alimony, child support or other maintenance payments?"]
["5. Are you a co-signor, guarantor or endorser for any loans or contracts?"]
["6. Are you insured for health or major medical coverage?"]
["7. Who is your accountant:"]