PERSONAL FINANCIAL STATEMENT

To induce Roche Surety & Casualty Company, Inc. to become surety for the Undersigned, or to accept the Undersigned as Indemnitor, the Undersigned submits the following Financial Statement.

NOTE: THIS FORM TO BE USED FOR PERSONAL FINANCIAL STATEMENT ONLY. NOT TO BE USED FOR BUSINESS STATEMENTS.

Name* :
E-mail* :
Address* :
Name of Wife/Husband:

Social Security No.*:

City*:

State*:

Zip*:

Home Phone No.*

Bus. Phone No.*

PERSONAL FINANCIAL STATEMENT AS OF (Date)

CURRENT ASSETS
Cash on Hand (Not in Bank)
Cash in Following Banks (Names and Addresses)

Stocks and Bonds (Schedule 1)
Accounts Receivable (Schedule 2)
Notes Receivable (Schedule 3)
Other Current Assets (Itemized)


TOTAL CURRENT ASSETS

FIXED ASSETS
Real Estate (Schedule 4)
Residence
Other
Cash Value of Life Insurance (Schedule 5)
Other Assets and Investments (Schedule 6)


TOTAL FIXED ASSETS
TOTAL ASSETS

CURRENT LIABILITIES
Notes Payable To (Names and Addresses)

Sales Contracts & Chattel Mtgs. (Schedule 6)
Accounts Payable
Other Current Liabilities (Schedule 6)

Current Year's Income Taxes Unpaid
Prior Year's Income Taxes Unpaid
Real Estate Taxes Unpaid
TOTAL CURRENT LIABILITIES

LONG TERM LIABILITIES
Real Estate Debt (Schedule 4)
Residence
Other
Borrowed on Life Insurance (Schedule 5)
Other Long Term Debt (Schedule 6)

TOTAL LONG TERM LIABILITIES
NET WORTH
TOTAL LIABILITIES AND NET WORTH

Contingent Liabilities

For Endorsements or Guarantees: $

For Other Purposes: $

Give Details:

SCHEDULE 1: STOCKS AND BONDS

Name of Security	No. Shares	If Any Pledged, State to Whom and For What Purpose	Dividends Paid Last Two Years	Market Value	Book Value





			TOTALS

SCHEDULE 2: ACCOUNTS RECEIVABLE

Name and Address (Street and City) From Whom Due	For What Due	When Sold	When Due	Amount



			TOTAL

SCHEDULE 3: NOTES RECEIVABLE

Name and Address (Street and City) From Whom Due	For What Due	How Secured	Date	Maturity	Book Value



			TOTALS

SCHEDULE 4: REAL ESTATE

Description of Property	Title in Name Of	Market Value	Cost	Date Acquired	Amount Encumbrance	Monthly Payments	Monthly Income




		TOTALS

SCHEDULE 5: LIFE INSURANCE – CASH VALUE

Name of Company	Policy Number	Name of Insured	Beneficiary	Face Value	Cash Value	Amount Borrowed



			TOTALS

SCHEDULE 6: GIVE DETAILS RELATIVE TO OTHER IMPORTANT ASSETS AND LIABILITIES

Authority is hereby granted to any individual, firm or corporation, and any financial institution to furnish Roche Surety & Casualty Company, Inc. upon its request with any information concerning the above statement or pertaining to the Undersigned's financial standing, credit or manner of meeting obligations.

Date:

Applicant Name:

Witness Name:

Place:

Signed and Sealed this ________________________________________________________________________day of , 20


Signature of Applicant: _________________________________________________________________________________________________________________

Notary: _______________________________________________________________________________________________________________________ (Seal)

I Accept the Terms & Conditions

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