Financial Statement


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Financial Statement Name__________________________________________Address_________________________________________ Account No._______________Social Security No._____________________Phone No.__________________________ _______________________________________________________________________________________________ For the purpose of obtaining loans with you, and otherwise procuring credit from time to time, I or we furnish the following statement of my or our financial condition as of _____________; and in the absence of a new written statement this is to be considered as a continuing statement ; and it is hereby expressly agreed that upon application for further credit, or renewal or extention of notes owing at any time to said bank, that this statement shall have the same force and effect as if delivered as an original statement of my or our financial condition at the time such further credit is requested or renewals or extensions granted.

Assets

Liabilities

Current Assets Cash and Investments Cash on hand and in banks Government Bonds and Investments Notes and Receivables Cash Value Life Insurance Total 1 Livestock For Sale No. Description _________ ___________ _________ ___________ _________ ___________ _________ ___________ _________ ___________ _________ ___________

$ Avg Wt __________ __________ __________ __________ __________ __________

Total 2 $ Breeding Livestock No. Description Avg Wt _________ ___________ __________ _________ ___________ __________ _________ ___________ __________ _________ ___________ __________ _________ ___________ __________ Total 3 $ Grain and Feed Grain Held for Sale(see back) Feed on Hand(see back) Growing Crops(see back) Supplies on Hand Prepaid Expenses

Value

Value

Total 4 $ (1 thru 4) Total Current Assets 5 $ Fixed Assests Machinery, Equipment, & Vehicles (see separate schedule) $ Real Esate(see back) ________________________________ $ Buildings & Improvements _______________________________ _______________________________ $ Total Fixed Assets 6$ (5 plus 6) Total Assets 7 $ Principal Balance less Principal Payments Due in 12 Months.

Current Liablities Encumbrances on Livestock & Equipment To:_________________________________ Security:____________________________ $ To:_________________________________ Security:____________________________ $ Notes, Contracts, & Lease Payments Due within 12 Months To: (1C)_____________________________ For_________Due Dt._________________ $ To: (2C)_____________________________ For_________Due Dt._________________ $ To: (3C)_____________________________ For_________Due Dt._________________ $ Real Estate Pmts Due in 12 Months To: (1RE)_________Due Dt._______________ PRIN:____________INT:__________________$ To: (2RE)_________Due Dt._______________ PRIN:____________INT:__________________$ To: (3RE)_________Due Dt._______________ PRIN:____________INT:__________________$ Cash Rent & Lease Pmts (see back) Open Accounts Payable, Credit Card To:_________________________________ $ To:_________________________________ $ To:_________________________________ $ To:_________________________________ $ To:_________________________________ $ Accrued Interest Payable To:___________________________________ To:___________________________________ Total Current Liabilities 8 $ Notes, Contracts & Leases Payable* To:(1C)________________________________$ To:(2C)________________________________$ To:(3C)________________________________$ To:(4C)________________________________$ Real Estate Mortgages & Contracts To:(1RE)____________________%_________$ To:(2RE)____________________%_________$ To:(3RE)____________________%_________$ To:(4RE)____________________%_________$ Total Long Term Liabilities 9$ Total Liabilites (8 plus 9) 10$ Net Worth 11 $ (10 plus 11) Total Liablities and Net Worth $

Wheat Wheat Rye Barley Barley Flax Oats Corn Soybeans Sunflowers Millet

Feed Grain and Crops Alfalfa Hay Mixed Hay Oatlage Corn Silage Corn Stover Straw

Bu. @ Bu. @ Bu. @ Bu. @ Bu. @ Bu. @ Bu. @ Bu. @ Bu. @ CWT. @ CWT. @

Rye Winter Wheat

Total Description

Ton @ Ton @ Ton @ Ton @ Ton @ Ton @

Acres @ Acres @

$ Tillable Acre

$

Real Estate Schedule Pasture Acres Cost

Value

Mortgage

Terms of Lease

Cost Per Acre

Total Owner

Tillable Acres

Real Estate Leased Pasture Acres

Total Machinery Insurance $__________________Company__________________________Agent___________________________ Livestock Insurance $__________________Company__________________________Agent___________________________ Crop Insurance $__________________Company__________________________Agent___________________________ Life Insurance $__________________Company__________________________Beneficiary_______________________ Life Insurance $__________________Company__________________________Beneficiary_______________________ Life Insurance $__________________Company__________________________Beneficiary_______________________ Vehicle Insurance $__________________Company__________________________Agent___________________________ In whose name is above real estate title held?___________________________________________________________________ Is real estate held in fee simple, leased, or under contract?________________________________________________________ My age is___________years. Marital Status_________________Children at home_________Ages_________________________ There are no judgements or suits pending against me at this time except____________________________________________ ___________________________________________________________________________________________________________ Do you have any partners in your business?__________If yes, state particulars:_______________________________________ ___________________________________________________________________________________________________________ Have you ever been adjudged a bankrupt?___________If yes, state particulars:_______________________________________ ___________________________________________________________________________________________________________ In submitting the foregoing statement the undersigned guarantees its accuracy with the intent that it be relied upon by the aforesaid bank in extending credit to the undersigned and warrants that (he) (she) (they) ha__ not knowingly withheld any information that might affect (his) (her) (their) credit; and the undersigned expressly agrees to notifly immediately said bank in writing of any material change in (his) (her) (their) financial condition whether application for further credit is made or not and in the absence of such written notice it is expressly agreed that said bank in granting new and continuing credit may rely upon this statement as having the same force and effect as if delivered upon the date additional credit is requested or existing credit extented or continured. You are authorized to verify this information and retain the application whether or not it is approved.

Signed this_____________day of________________, 20_______at____________________________________________________ ____________________________________________________ Signature Signature

____________________________________________________

Subscribed and sworn to before me this ________day of __________________________________, 20_______. SEAL

____________________________________________________