FINANCIAL STATEMENT PERSONAL INFORMATION. Name. Home Address. Social Security # Home Phone. Employer. Employer Address. Title.

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1 FINANCIAL STATEMENT Submitted to Farmers State Bank as of Page 1 of 5 Name APPLICANT PERSONAL INFORMATION Name CO-APPLICANT Home Address Home Address Address Address Social Security # Birthdate Social Security # Birthdate Home Cell Home Cell Employer Employer Employer Address Employer Address Title # of Years Title # of Years Accountant Name Accountant Name Investment Advisor/Broker Name Investment Advisor/Broker Name Insurance Advisor Name Insurance Advisor Name # of acres farmed ACRES PROJECTED YIELDS # of acres owned Corn Corn # of acres - cash rent Wheat Wheat # of acres - share crop Soybeans Soybeans Do you have Federal Crop Insurance? Yes No If yes, agent's name: ASSETS Current Assets Deposits in Banks & Other Financial Inst (Sch 1 ) Cash of Life Insurance (Sch 2) Notes and Accounts Receivable Crops on Hand (Schedule 3) Cash in Growing Crops (Schedule 4) Livestock Held for Sale (Schedule 5) Total Current Assets Intermediate Assets Marketable Stocks & Bonds (Sch 6) Stocks in Closely Held Corporations (Sch 7) Assets of Proprietorships Assets in Partnerships & Joint Ventures LIABILITIES Current Liabilities Notes Payable (Sch 13) Accounts Payable Credit Cards Loans on Life Insurance (Sch 2) Taxes Due - Income Total Current Liabilities Intermediate Liabilities Vehicle, Boats, Machine & Equipment Loans (Sch 8) Liabilities of Proprietorships Liabilities of Partnerships/Joint Ventures Vehicles, Boats, Machinery, & Equipment (Sch 8) Breeding Stock (Schedule 9) Total Intermediate Assets Long Term Assets Wholly Owned Real Estate (Sch 10) Partially Owned Real Estate (Sch 11) Vested Interest in Pension/Retirement Accts (Sch 12) Personal Property Furniture etc. Total Long Term Assets ASSETS Total Intermediate Liabilities Long Term Liabilities Real Estate Mortgages (Sch 10) Partially Owned Real Estate Mortgages (Sch 11) Long Term Liabilities LIABILITIES NET WORTH

2 Page 2 of 5 Schedule 1 - DEPOSIT ACCOUNTS NAME OF FINANCIAL INSTITUITON AND LOCATION ACCOUNT TYPE NAME OF FINANCIAL INSTITUITON AND LOCATION ACCOUNT TYPE Schedule 2 - LIFE INSURANCE Name of Person Insured Beneficiary Face Amount Cash Policy Loans Policy Assigned? S Schedule 3 - CROPS ON HAND Crop Bushels or Tons $ per bushel Schedule 4 - GROWING CROPS Crop Full Share Acres $ per acre invested Schedule 5 - LIVESTOCK HELD FOR SALE Number Description Weight Price Schedule 6 - ABLE STOCKS/BONDS NYSE, AMEX, NASDAQ # OF SHARES FACE OF BONDS DESCRIPTION REGISTERED IN NAME OF IF PLEDGED TO WHOM? ACQUIRED COST

3 Page 3 of 5 Schedule 7 - STOCK IN CLOSELY HELD CORPORATIONS Please provide F/S if total value exceeds 10% of your net worth # SHARES OWNED % OWNED CORPORATION NAME STOCK HELD IN THE NAME OF STOCKHOLDER'S EQUITY ANNUAL STATEMENT OF SHARES Schedule 8 - VEHICLES, BOATS, MACHINERY, AND EQUIPMENT YEAR DESCRIPTION MAKE MODEL YEAR ACQ COST LOAN, IF APPLICABLE LOAN PAYABLE TO RATE ORIG PMT TERM FREQ # OF MOS PAYMENT AMOUNT S Schedule 9 - BREEDING LIVESTOCK Number Description Weight Price

4 Page 4 of 5 Schedule 10 - WHOLLY OWNED REAL ESTATE LOCATION OR ADDRESS DESCRIPTION OF PROPERTY TITLE IN THE NAME OF COST/ YR ACQUIRED MORTGAGE MORTGAGE PAYABLE TO Amount due and term per per per Schedule 11 - PARTIALLY OWNED REAL ESTATE LOCATION OR ADDRESS DESCRIPTION OF PROPERTY TITLE IN THE NAME OF COST/ YR ACQUIRED MORTGAGE % of Ownership Ownership Amount Schedule 12 - VESTED INTEREST IN PENSION/RETIREMENT ACCOUNTS ACCOUNT TYPE IN NAME OF INVESTED WITH Schedule 13 - OTHER LOAN PAYABLES NAME OF LENDER ORIGINAL ORIGINAL AMOUNT LOAN REPAYMENT TERMS PAYMENT AMOUNT COLLATERAL PLEDGED OTHER COMAKERS/ ENDORSERS

5 Page 5 of 5 SOURCE OF INCOME FOR YEAR ENDED (Attach a copy of your most recent Income Tax Return and K-1's) Salaries - Yours Salaries - Your spouses (if applicable) Bonuses & Commissions Dividends Interest Net Profits from: Rental Property Proprietorships Partnerships Are you indirectly liable for obligations of others? Yes No Name of Borrower: Total Amount Owed: Lender: Description: Name of Borrower: Total Amount Owed: Lender: Description: CONTINGENT LIABILITIES If yes, list and describe. If the obligation is for a business or if you need additional space, list and describe on an attachment. Total Amount as endorser, comaker or guarantor: PERSONAL INFORMATION Number of Dependents Ages Are you obligated to pay alimony, child support, or separate maintenance maintenance payments? Yes No If yes, provide details: Joint Ventures Other Income: (Alimony, child support or separate maintenance income is not needed if not considered as a basis for repaying this debt) INCOME Are you a defendant in any suits or legal actions? Yes No Have you ever declared bankruptcy or had any judgements recorded against you? Yes No If yes, give details (dates, location, amounts on a separate page) Do you have a will? Yes No If yes, who is the executor? Do you have disability insurance? If so, what is the monthly amount? What years are covered? REPRESENTATIONS AND WARRANTIES The information contained in this statement is provided to induce Farmers State Bank to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of the undersigned. The undersigned acknowledge and understand that Farmers State Bank is relying on the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. Each of the undersigned represents, warrants, and certifies that the information provided herein is true, correct, and complete. Each of the undersigned agrees to notify Farmers State Bank 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 obligations to Farmers State Bank. In the absence of such notice or a new full written statement, this should be considered a continuing statement and substantially correct. If the undersigned fail to notify Farmers State Bank as required above, or if any information herein should prove to be inaccurate or incomplete in any material respect, Farmers State Bank may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable. Farmers State Bank is authorized to make all inquiries it deems necessary to verify accuracy of the information contained herein and to determine the creditworthiness of the undersigned. The undersigned authorize any person or consumer reporting agency to give Farmers Sate Bank any information they may have on the undersigned. Each of the undersigned authorizes Farmers State Bank to answer questions about Farmers State Bank s credit experience with the undersigned. As long as any obligation or guaranty of the undersigned to Farmers State Bank 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 Farmers State Bank shall be Farmers State Bank s property. Yes No THE UNDERSIGNED HAVE READ AND FULLY UNDERSTAND THE FOREGOING REPRESENTATIONS AND WARRANTIES APPLICANT SIGNATURE CO-APPLICANT SIGNATURE If this is an application for joint credit, Applicant and Co-applicant each agree that we intend to apply for joint credit. (initial below) Initial for joint credit Initial for joint credit Received by: Date:

6 NOTES:

We Want To Be Your Bank!

We Want To Be Your Bank! Instructions for completing financial statement (electronically): 1) There are eight tabs to the Excel spreadsheet attachment: Tab 1: Instruction sheet Tabs 2-5: Financial Statements Tab 6: Contingent