APPLICANT Full Legal Name Social Security # Date of Birth Phone # Street Apt. # City State ZIP Years at Residence Own Rent Monthly Rent (if applicable) # of Dependents Martial Status* Single Married Divorced Widowed Employer Current PositionTitle Years in Position Email Address *Marital status (answer only if this financial statement is provided in connection with a request for secured credit or applicant is seeking a joint account with spouse). 294 Grove Lane East, Suite 120, Wayzata, MN 55391 1
CO-APPLICANT Check box and initial if it is your intent to be a co-borrower or joint guarantor. Full Legal Name Social Security # Date of Birth Phone # Street Apt. # City State ZIP Years at Residence Own Rent Monthly Rent (if applicable) # of Dependents Martial Status* Single Married Divorced Widowed Employer Current PositionTitle Years in Position Email Address *Marital status (answer only if this financial statement is provided in connection with a request for secured credit or applicant is seeking a joint account with spouse). VALUATION EFFECTIVE AS OF: 294 Grove Lane East, Suite 120, Wayzata, MN 55391 2
DATA ENTERED ON SCHEDULES 1-13 NEEDS TO BE APPLIED HERE Assets Description Amount Cash (Schedule 1) Securities Owned (Schedule 2) Retirement Accounts (Schedule 3) Life Insurance (Schedule 4) Residence(s) (Schedule 5) Other Real Estate Owned (Schedule 6) Automobiles, RVs, Boats, ATVs, etc. (Schedule 7) Due from Others (Schedule 8) Personal Property and Other Assets (Schedule 9) Liabilities Description Amount tes Payable (Schedule 10) Loans on Life Insurance (Schedule 4) Mortgages on Residence(s) (Schedule 11) Mortgages or Liens on Other Real Estate (Schedule 12) Other Obligations (Schedule 13) 294 Grove Lane East, Suite 120, Wayzata, MN 55391 3
DATA ENTERED ON SCHEDULES 1-13 NEEDS TO BE APPLIED HERE CONT. Net Worth Total Liabilities and Net Worth Annual Income Income Applicant Co-applicant Salary Commissions Dividends & Interest Rentals Alimony, Child Support, etc.** Other 294 Grove Lane East, Suite 120, Wayzata, MN 55391 4
SCHEDULE 1: CASH (SAVINGS, MONEY MARKET, CDS, ETC.) Financial Institution Name Account Type Account Name Pledged? (YN) SCHEDULE 2: SECURITIES OWNED Description # of Shares Type Registered Name Pledged? (listedunlisted) (YN) 294 Grove Lane East, Suite 120, Wayzata, MN 55391 5
SCHEDULE 3: RETIREMENT ACCOUNTS (401K S, IRA S, PENSIONS, ETC.) Description Registered Name SCHEDULE 4: LIFE INSURANCE Insured Insurance Company Beneficiary Face Value of Policy Cash Value Loans 294 Grove Lane East, Suite 120, Wayzata, MN 55391 6
SCHEDULE 5: RESIDENCE(S) (HOMESTEAD, VACATION PROPERTIES, CABINS, ETC.) Address Property Type Owned by Year Acquired Cost Market Value Property Type: SF = Single Family, T = TownhomeCondo, L = LandAcreage, O = Other n-income Producing Property SCHEDULE 6: OTHER REAL ESTATE OWNED (INCLUDES INVESTMENT RE OWNED) Address Property Type Owned by % Owned Monthly Income Year Acquired Cost Market Value Property Type: SF = Single Family, MF = Multiple Family, C = CommercialIndustrial, L = LandAcreage 294 Grove Lane East, Suite 120, Wayzata, MN 55391 7
SCHEDULE 7: AUTOMOBILES, RVS, BOATS, ATVS, ETC. Make Model Style Owned by Year Market Value SCHEDULE 8: DUE FROM OTHERS (FRIENDS, RELATIVES, MORTGAGES, CONTRACTS FOR DEED OWNED, ETC.) Name of Debtor Owed to Collateral Maturity Date Payment ($frequency) SCHEDULE 9: PERSONAL PROPERTY AND OTHER ASSETS Description Owned by Market Value 294 Grove Lane East, Suite 120, Wayzata, MN 55391 8
SCHEDULE 10: NOTES PAYABLE (DUE TO BANKS, DUE TO OTHERS, INSTALLMENT CONTRACTS, STUDENT LOANS, CREDIT CARDS, ETC.) To Whom Payable Payment ($frequency) Collateral SCHEDULE 11: MORTGAGES ON RESIDENCE(S) (HOMESTEAD, VACATION PROPERTIES, CABINS, ETC.) Address Payment ($frequency) Lender Int. Rate Maturity Date 294 Grove Lane East, Suite 120, Wayzata, MN 55391 9
SCHEDULE 12: MORTGAGES OR LIENS ON OTHER REAL ESTATE OWNED (INCLUDES INVESTMENT RE OWNED - SEE THE TAB FOR MORE INFO) Address Payment ($frequency) Lender Int. Rate Maturity Date SCHEDULE 13: OTHER OBLIGATIONS (ALIMONY, CHILD SUPPORT, LAWSUITS, TAX LIABILITIES, TUITION, ETC.) Description Payment ($frequency) 294 Grove Lane East, Suite 120, Wayzata, MN 55391 10
SCHEDULE 14: CONTINGENT LIABILITIES GUARANTEED BY APPLICANT OR CO-APPLICANT Name of Debtor Lender Collateral Payment ($frequency) Maturity Date APPLICANT GENERAL INFORMATION Have you OR any company in which you arewere an owner ever declared Bankruptcy? Have you OR any company in which you arewere an owner ever had a judgment filed against you? Have you ever owned real estate that has been foreclosed upon OR been part of a short sale? Are any assets held in a trust? Are you a Co-signer or Guarantor of any other debt? If, complete Schedule 14 above. Have you made a will? Have you ever been convicted of a felony? If you answered to Questions 1-6 above, please explain in the comment box below or attach an explanation: 294 Grove Lane East, Suite 120, Wayzata, MN 55391 11
CO-APPLICANT GENERAL INFORMATION Have you OR any company in which you arewere an owner ever declared Bankruptcy? Have you OR any company in which you arewere an owner ever had a judgment filed against you? Have you ever owned real estate that has been foreclosed upon OR been part of a short sale? Are any assets held in a trust? Are you a Co-signer or Guarantor of any other debt? If, complete Schedule 14 above. Have you made a will? Have you ever been convicted of a felony? If you answered to Questions 1-6 above, please explain in the comment box below or attach an explanation: 294 Grove Lane East, Suite 120, Wayzata, MN 55391 12
REPRESENTATIONS AND WARRANTIES The foregoing statement, submitted for the purpose of obtaining credit, is true and correct in every detail and fairly shows myour financial condition at the time indicated. Iwe will give you prompt subsequent substantial change in such financial condition occurring before written notice of any discharge of my our obligations to you. Iwe understand that you will retain this personal financial statement whether or not you approve the credit in connection with which it is submitted. You are authorized to check myour credit, which may include a background check and employment history or any other information contained herein. THE UNDERSIGNED CERTIFY THAT THE INFORMATION CONTAINED ON THIS FORM HAS BEEN CAREFULLY REVIEWED AND THAT IT IS TRUE AND CORRECT IN ALL RESPECTS. Applicant Date Co-Applicant Date 294 Grove Lane East, Suite 120, Wayzata, MN 55391 13