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["  "]
{"$rows_empty":7}
[{"$nulls":15},"PERSONAL FINANCIAL STATEMENT AS OF:"]
[{"$nulls":15},"SUBMITTED TO:   Farmers & Merchants Savings Bank "]
[]
["PERSONAL INFORMATION"]
[]
[{"$nulls":30},"APPLICANT"]
["Name:"]
["Home Address:"]
["Home Phone:",{"$nulls":20},"Social Security No.:",{"$nulls":22},"Date of Birth:"]
["Employer:",{"$nulls":27},"Address:"]
["Business Phone No.:",{"$nulls":19},"No. of Years with Employer:",{"$nulls":17},"Title/Position:"]
["Name of Previous Employer & Position (If With Current Employer Less Than 3 Yrs):"]
["No. of Years:",{"$nulls":9},"Address:",{"$nulls":29},"Business Phone No.:"]
["Name of your Accountant:",{"$nulls":39},"Business Phone No.:"]
["Name of your Attorney:",{"$nulls":39},"Business Phone No.:"]
["Name of your Investment Advisor/Broker:",{"$nulls":39},"Business Phone No.:"]
["Name of your Insurance Advisor:",{"$nulls":39},"Business Phone No.:"]
[{"$nulls":30},"CO-APPLICANT"]
["Name:"]
["Home Address:"]
["Home Phone:",{"$nulls":20},"Social Security No.:",{"$nulls":22},"Date of Birth:"]
["Employer:",{"$nulls":27},"Address:"]
["Business Phone No.:",{"$nulls":19},"No. of Years with Employer:",{"$nulls":17},"Title/Position:"]
["Name of Previous Employer & Position (If With Current Employer Less Than 3 Yrs):"]
["No. of Years:",{"$nulls":9},"Address:",{"$nulls":29},"Business Phone No.:"]
[]
[{"$nulls":12},"Cash Income & Expenditures Statement for Year Ended",{"$nulls":30},"(Omit Cents)"]
[]
[{"$nulls":5},"ANNUAL INCOME",{"$nulls":13},"AMOUNT ($)",{"$nulls":17},"ANNUAL EXPENDITURES",{"$nulls":15},"AMOUNT ($)"]
["Salary (applicant)",{"$nulls":33},"Federal Income and Other Taxes"]
["Salary (co-applicant)",{"$nulls":33},"State Income and Other Taxes"]
["Bonuses & Commissions (applicant)",{"$nulls":33},"Rental Payments, Co-op or Condo Maint"]
["Bonuses & Commissions (co-applicant)",{"$nulls":33},"Mortgage Payments - Residential"]
["Rental Income",{"$nulls":33},"Mortgage Payments - Investment"]
["Interest Income",{"$nulls":33},"Property Taxes - Residential"]
["Dividend Income",{"$nulls":33},"Property Taxes - Investment"]
["Capital Gains",{"$nulls":33},"Interest & Principal Loan Payments"]
["Partnership Income",{"$nulls":33},"Insurance"]
["Other Investment Income",{"$nulls":33},"Investments"]
["Other Income (List)**",{"$nulls":33},"Alimony/Child Support"]
["Gambling",{"$nulls":33},"Tuition"]
[{"$nulls":34},"Other Living Expense"]
[{"$nulls":34},"Medical Expenses"]
[{"$nulls":34},"Other Expenses"]
["TOTAL INCOME   ",{"$nulls":33},"TOTAL EXPENDITURES  "]
[]
[]
[null,"Any significant changes expected in the next 12 months?",{"$nulls":27},"Yes",{"$nulls":5},"No  (If Yes, Attach information)"]
[]
[null,"** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation."]
[]
[]
[{"$nulls":23},"Balance Sheet"]
[{"$nulls":19},"As Of:"]
[]
[{"$nulls":14},"ASSETS",{"$nulls":31},"LIABILITIES"]
["Cash in this Bank   (including money market account, CDs)",{"$nulls":33},"Notes Payable to this Bank Secured"]
[{"$nulls":34},"Notes Payable to this Bank unsecured"]
["Cash in other Financial Institutions (List)( including money market accounts, CD)",{"$nulls":33},"Notes Payable to Others (Schedule E)"]
[{"$nulls":35},"Secured"]
[{"$nulls":35},"Unsecured"]
[{"$nulls":34},"Accounts Payable (including credit cards)"]
[{"$nulls":34},"Margin Accounts"]
[{"$nulls":34},"Notes Due:  Partnership (Schedule D)"]
["Readily Marketable Securities (Schedule A1)",{"$nulls":33},"Taxes Payable"]
["Non-Readily Marketable Securities (Schedule A2)",{"$nulls":33},"Mortgage Debt (Schedule C1)"]
["Accounts and Notes Receivable",{"$nulls":33},"Invetment Debt (Schedule C2)"]
["Net Cash Surrender Value of Life Insurance (Schedule B)",{"$nulls":33},"Life Insurance Loans (Schedule B)"]
["Residential Real Estate (Schedule C1)",{"$nulls":33},"Other Liabilities (List)"]
["Real Estate Investments (Schedule C2)"]
["Partnerships / PC Interests (Schedule D)"]
["IRA, Keogh, Profit-Sharing & Other Vested Retirement Accts."]
["Deferred Income (number of years deferred)"]
["Personal Property (including automobiles)"]
["Other Assets (List)"]
[{"$nulls":34},"TOTAL LIABILITIES  "]
[{"$nulls":34},"NET WORTH  "]
[]
[]
["CONTINGENT LIABILITIES",{"$nulls":47},"Yes",null,"No",{"$nulls":4},"Amount"]
["Are you a guarantor, co-maker, or endorser for any debt of an individual, corporation, or partnership?"]
["Do you have any outstanding letters of credit or surety bonds?"]
["Are there any suits or legal actions pending against you?"]
["Are you contingently liable on any lease or contract?"]
["Are any of your tax obligations past due?"]
["What would be your total estimated tax liability if you were to sell your major assets?"]
["If yes for any of the above, give details:"]
[]
[]
[]
[]
["Schedule A1 - READILY MARKETABLE SECURITIES (including U.S. Governments and Municipals)"]
["No. of Shares (Stock) or Face Value (Bonds)",{"$nulls":4},"Description",{"$nulls":16},"Owners",{"$nulls":16},"Where Held",{"$nulls":7},"Cost",null,null,null,"Current Market Value",null,null,null,"Pledged"]
[]
[{"$nulls":55},"Yes",null,"No"]
[]
[]
[]
[]
[]
[{"$nulls":48},"Total"]
["Schedule A2 - NON-READILY MARKETABLE SECURITIES (closely held, thinly traded, or restricted stock)"]
["No. of Shares (Stock) or Face Value (Bonds)",{"$nulls":4},"Description",{"$nulls":16},"Owners",{"$nulls":16},"Where Held",{"$nulls":7},"Cost",null,null,null,"Current Market Value",null,null,null,"Pledged"]
[]
[{"$nulls":55},"Yes",null,"No"]
[]
[]
[]
[]
[]
[{"$nulls":47},"Total"]
[]
[]
[]
["Schedule B - Life Insurance (use additional sheet if necessary)"]
["Insurance Company",{"$nulls":11},"Face Amount of Policy",{"$nulls":5},"Type of Policy",{"$nulls":6},"Beneficiary",{"$nulls":11},"Cash Surrender Value",{"$nulls":4},"Amount Borrowed",{"$nulls":4},"Beneficiary"]
[]
[]
[]
[]
[]
[]
[{"$nulls":36},"Asset Total",{"$nulls":10},"Liability Total"]
[]
["Personal Residence & Real Estate Investments, Mortgage Debt (Majority Ownership only)"]
["Schedule C1 - Personal Residence"]
["Property Address",{"$nulls":13},"Legal Owner",{"$nulls":11},"Purchase",{"$nulls":5},"Market Value",{"$nulls":4},"Present Loan Balance",{"$nulls":4},"Interest Rate",null,null,"Loan Maturity Date",null,null,"Monthly Payment",null,null,null,"Lender"]
[]
[{"$nulls":26},"Year",null,null,"Price"]
[]
[]
[]
[]
[{"$nulls":19},"Total Personal Residence",{"$nulls":23},"Total Mortgage Debt"]
["Schedule C2 - Investment"]
["Property Address",{"$nulls":13},"Legal Owner",{"$nulls":11},"Purchase",{"$nulls":5},"Market Value",{"$nulls":4},"Present Loan Balance",{"$nulls":4},"Interest Rate",null,null,"Loan Maturity Date",null,null,"Monthly Payment",null,null,null,"Lender"]
[]
[{"$nulls":26},"Year",null,null,"Price"]
[]
[]
[]
[]
[{"$nulls":23},"Total Investment",{"$nulls":19},"Total Investment Debt"]
[]
["Schedule D - Partnerships (less than majority ownership for real estate partnership)*"]
["Type of Investment",{"$nulls":16},"Date of Initial Investment",{"$nulls":7},"Cost",{"$nulls":7},"Percent Owned",null,null,null,"Current Market Value",{"$nulls":7},"Balance Due on Partnerships: Notes, Cash Call",{"$nulls":7},"Final Contribution Date"]
[]
[]
["Business/Professional (Indicate name):"]
[]
[]
["Investments (Including Tax Shelters):"]
{"$rows_empty":7}
[{"$nulls":24},"Total Current Market Value",{"$nulls":28},"Total Due"]
["* Note:  For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investments or S-corporations, schedule K-1s."]
[]
["Schedule E - Notes Payable"]
["Due To",{"$nulls":17},"Type of Facility",{"$nulls":9},"Amount of Line",{"$nulls":4},"Secured",null,null,null,"Collateral",{"$nulls":7},"Interest Rate",null,null,"Maturity",{"$nulls":5},"Unpaid Balance"]
[]
[{"$nulls":33},"Yes",null,"No"]
{"$rows_empty":8}
["Please Answer The Following Questions:"]
[]
[]
[1,null,"Income tax returns filed through (date):",{"$nulls":23},"Are any returns currently being audited or contested?",{"$nulls":26},"Yes",null,null,null,"No"]
[null,null,"If yes, what year(s)?"]
[]
[2,null,"Have (either of) you or any firm in which you were a major owner ever declared bankruptcy?",{"$nulls":44},"Yes",{"$nulls":4},"No"]
[null,null,"If yes, please provide details:"]
[]
[3,null,"Have you drawn a will?",{"$nulls":15},"Yes",{"$nulls":4},"No"]
[null,null,"If yes, please furnish the name of the executor(s) and year will was drawn:"]
[]
[4,null,"Number of dependents (excluding self) and relationship to applicant:"]
[]
[5,null,"Did you include two years federal and state tax returns?",{"$nulls":29},"Yes",{"$nulls":4},"No"]
[]
[6,null,"Do (either of) you have a line of credit or unused credit facility at any other institution(s)?",{"$nulls":43},"Yes",{"$nulls":4},"No"]
[null,null,"If so, please indicate where, how much and name of bank:"]
[]
[7,null,"Do you anticipate any substantial inheritances?",{"$nulls":26},"Yes",{"$nulls":4},"No"]
[null,null,"If yes, please explain:"]
[]
[]
[]
["Representations and Warranties"]
[]
["   The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the"]
["undersigned or to others upon the guarantee of the undersigned.  The undersigned acknowledge and understand that you are relying"]
["on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the"]
["undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material"]
["adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the"]
["undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you.  In the absence of "]
["such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct.  "]
["If the undersigned fail to notify you as required above, or if any of the information herein should prove to be inaccurate or"]
["incomplete in any material respect, you may declare the indebtedness of the undersigned or the indebtedness "]
["guaranteed by the undersigned, as the case may be, immediately due and payable.  You are authorized to make all inquires "]
["you deem necessary to verify the accuracy of the information contained herein and to determine the credit worthiness of the "]
["undersigned.  The undersigned authorize any person or consumer reporting agency to give you any information it may have on"]
["the undersigned.  Each of the undersigned authorizes you to answer questions about your credit experience with the "]
["undersigned.  As long as any obligation or guarantee of the undersigned to you is outstanding, the undersigned shall supply"]
["annually an updated financial statement.  This personal financial statement and any other financial or other information that "]
["the undersigned give you shall be your property."]
[]
[]
[]
[null,null,"Signature",{"$nulls":29},"Signature"]
[]
["Submission of this financial statement and information contained herein consititutes a request for credit in the amount of"]
["$_____________________________________ for the purpose of ______________________________________________"]
["__________________________________________"]
[]
[null,null,null,"I intend to apply for individual credit"]
[{"$nulls":30},"Your Signature"]
[]
[]
[{"$nulls":30},"Date"]
[]
[null,null,null,"We intend to apply for joint credit"]
[]
[null,"Date",{"$nulls":28},"Your Signature"]
[]
[]
[null,"Date",{"$nulls":28},"Joint Applicant's Signature"]