Fill and Sign the Personal Financial Statement Parke Bank Form

Financial Statement page - 1 - Initials: ________ __________ PERSONAL FINANCIAL DISCLOSURE STATEMENT * * * To: Date: Individual InformationName: Address: City: State!!Zip Occupation: Phone: Current AssetsCurrent LiabilitiesCash on Hand or in Banks Notes Payable (Secured)(Schedule F) Other Cash: Notes Payable (Unsecured)(Schedule G) Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H) Residence Auto Loans (Schedule I) Motor Vehicles (Schedule B) Unpaid Taxes and Interest US Government Securities (Schedule C) Due to Brokers Non-Marketable Securities (Schedule D) Open Accounts Stocks (Schedule E) Credit Cards (List): Other Personal Property Life Insurance Cash Value Business Interests Notes Receivable Other Assets:Other: Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES Total Assets NET WORTH Individual Income Information (Annual)Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent LiabilitiesGuarantor, Co-maker Lease or Contracts Legal Claims Other: Financial Statement page - 1 - Initials: ________ __________SCHEDULE “A” REAL ESTATEDescription of Real Estate Cost Market Value Date Acquired $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) Financial Statement page - 2 - Initials: ________ __________ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ I certify this Statement to be true and correct as of the date indicated:_________________________________Signature JOINT FINANCIAL DISCLOSURE STATEMENT * * * To: Date: Financial Statement page - 3 - Initials: ________ __________Individual InformationJoint Party InformationName: Name: Address: Address: City: State:!!Zip City: State:!!Zip Occupation: Occupation: Phone: Phone: Current AssetsCurrent LiabilitiesCash on Hand or in Banks Notes Payable (Secured)(Schedule F) Other Cash: Notes Payable (Unsecured)(Schedule G) Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H) Residence Auto Loans (Schedule I) Motor Vehicles (Schedule B) Unpaid Taxes and Interest US Government Securities (Schedule C) Due to Brokers Non-Marketable Securities (Schedule D) Open Accounts Stocks (Schedule E) Credit Cards (List): Other Personal Property Life Insurance Cash Value Business Interests Notes Receivable Other Assets:Other: Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES Total Assets NET WORTH Individual Income Information (Annual)Joint Party Income Information (Annual)Salary Salary Bonus Bonus Commissions Commissions Dividends Dividends Rental Income Rental Income Other Income (List):Other Income (List): Total Income Total Income Contingent LiabilitiesContingent LiabilitiesGuarantor, Co-maker Guarantor or Co-Maker Lease or Contracts Lease or Contracts Legal Claims Legal Claims Other: Other: Financial Statement page - 2 -SCHEDULE “A” REAL ESTATEDescription of Real Estate Cost Market Value Date Acquired $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ Financial Statement page - 3 - SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) $ $ $ $ $ $ $ $ $ $ $ $ Total $ $ We/I Certify this Statement to be true and correct as of the date indicated:_________________________________ ______________________________________SignatureSignature