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.

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
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
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
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

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.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________(Seal)

Roche Surety & Casualty Company, Inc. is a BBB Accredited Insurance Company in Tampa, FL