Application - by Applicant only jointly with____________________________

Relationship ____________________________

APPLICANTS (S)

Name of Applicant __________________________________

Financial Condition as of __________________________ Year ____

Resident _______________________________________________

Occupation _________________________________________

Birth date __________ Telephone Number ( ____ ) ______________

Employer _________________________________________

ASSETS	DOLLARS	CENTS	LIABILITIES & NET WORTH	DOLLARS	CENTS
Cash on hand			Notes Payable to this Bank
Cash in this Bank			Notes payable to ( )Bank
Cash in ( )Bank			Other notes & Installment Contracts Payable (See Schedule E)
Cash Value Life Ins (see Schedule A)			Accounts Payable
Real Estate (see Schedule B)			Unpaid Real Estate Taxes
U.S. Government & marketable Securities ( See Schedule C)			Liability for Income Taxes
Non-Marketable Securities (Schedule D)			Mortgages on Real Estate
Automobiles & Other Personal Property			Other Liabilities - Itemize:
Other Assets-Itemize:
			Total liabilities
			Net Worth
TOTAL			TOTAL

REAL ESTATE OWNED

LAND AND BUILDINGS OWNED AND MORTGAGES PAYABLE Attach Separate Schedule if Necessary

Parcel No.

Location

Description of Buildings

Name of Owner of Record

Owner’s Valuation

Assessed Value

Insured For

Taxes in Arrears

1

Parcel No.

Mortgage

Amount

Held by

Rate Interest

Maturity Date

Amount Due within 1 yr.

Terms of Payment On Balance

Mortgage Interest in Arrears

1

1^st

2^nd

Parcel No.

Location

Description of Buildings

Name of Owner of Record

Owner’s Valuation

Assessed Value

Insured For

Taxes in Arrears

2

Parcel No.

Mortgage

Amount

Held by

Rate Interest

Maturity Date

Amount Due within 1 yr.

Terms of Payment On Balance

Mortgage Interest in Arrears

1^st

2^nd

TOTALS: (as shown on statement)

Give details concerning any mortgage installments or interest in arrears _________________________________________________

___________________________________________________________________________________________________________

U.S. GOVERNMENT & MARKETABLE SECURITIES (Attach Separate Sheet if Necessary)
No.Shares or Bonds	Name of Security	Where Traded	In Whose Name Reg.	Market Value Statement Date	Valuation Used in Statement	If Pledged or Loaned State to Whom

NON-MARKETABLE SECURITIES (Attach Separate Sheet if Necessary)
No.Shares or Bonds	Name of Security	In Whose Name Reg.	Source of Value	Valuation Used in Statement	If Pledged or Loaned State to Whom