* ASSETS			* LIABILITIES
Cash		Due to Banks (unsecured)
Stocks, bonds, etc		Credit Cards
Accounts Receivable		Taxes
Notes Receivable		Accounts Payable
Vehicles		Notes Payable
Equipment		Due on Inventory
Home		Due on Real Estate
Real Estate		Other Liabilities
IRA		Total Liabilities
Other Assets		Net Worth
TOTAL ASSETS		TOTAL LIAB. and NET WORTH

* Additional information may be required to verify balances over $10,000.

SOURCES OF INCOME FOR YEAR ENDED

OTHER LIABILITIES

Salary, bonuses & commissions	$	Do you have any contingent liabilities? No Yes If Yes, explain
Dividends	$
Real Estate Income	$
Other income 1	$	Endorser, co-maker of guarantor?	$
Other income 2	$	On Leases or contracts?	$
Other income 3	$	Legal Claims (Judgments, etc)	$
Other income 4	$	Other special debt	$
TOTAL	$	Amount of contested tax liens	$

Are any assets owned by a trust? No Yes If Yes, describe	Ever declared bankrupt? No Yes If Yes, explain
Do you have a will? No Yes   If Yes, Name the executor	Are you a defendant in any suits or legal action? No Yes If Yes, explain
Are you a partner or officer in any other venture? No Yes If Yes, describe	Are any assets pledged? No Yes If Yes, explain
Any other obligations, alimony, child support, etc? No Yes If Yes, explain	Income tax paid through Year 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Name your personal bank