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888.725.2207 www.norwaysavings.bank MEMBER FDIC
Personal Financial Statement (PFS) Instructions
Two options for completing this document:
1. Print the document and provide information in writing OR
2. Save this document to your computer and enter your data into the file.Please include your business name and “PFS” in the name of the saved file.
o Print the completed form and sign.
Two options for submitting your completed PFS:
1. Fax, mail, or drop it off to your Norway Savings Bank commercial lender OR
2. Electronic Submission: Please contact your lender to request sending yourPFS via secure encrypted email and instructions for using the service. If youhave scanning capability, you can scan your signed document and attach it tothe reply of a secure message using our ZixCorp Message Service.
To protect the confidentiality of your information please DO NOT ATTACHyour Personal Financial Statement to regular email.
For a list of commercial lenders, please visit: https://www.norwaysavings.bank/business-banking/business-loans/meet-the-commercial-team/
Your privacy is important to us! Emails are like postcards – everyone wants to read them! We welcome your emails, however, to protect your privacy never include personal information in your message unless you are using secure encrypted email. Thank you for banking with Norway Savings Bank!
PERSONAL FINANCIAL STATEMENT AS OF: _______________________
Title/Position: No. Years with Employer:
No. Years with Employer:Title/Position:
Name and Address of previous employer(if with current employer less than 3 years):
Title/Position: No. Years with Employer:
Name, Phone No. of your Accountant:
Name, Phone No. of your Attorney:
Name, Phone No. of your Investment Advisor/Broker:
Applicant Name:
Name & Address of previous employer (if with current employer less than 3 years):
Home Phone:
Title/Position: No. Years with Employer:
Cell Phone: Work Phone:
Address of Employer:
SUBMITTED TO: Norway Savings Bank
PERSONAL INFORMATION: (Applicant)
E-Mail Address:
Employer:
Name, Phone No. of your Insurance Advisor:
Home Address:
PERSONAL INFORMATION: (Co-Applicant)
Co-Applicant Name:
Home Phone: Cell Phone:
Date of Birth: Social Security No.:
Name, Phone No. of your Attorney:
Name, Phone No. of your Investment Advisor/Broker:
Name, Phone No. of your Insurance Advisor:
Name, Phone No. of your Accountant:
Home Address:
Address of Employer:
E-Mail Address:
Employer:
Date of Birth: Social Security No.:
Work Phone:
Balance Sheet as of __________________________Amount ($) Amount ($)
Pledged?Yes / No
*If not enough space, attach a separate schedule or brokerage statement and enter totals only
Rate Maturity Unpaid Balance%%%
Face Amount Amount Cash Surrenderof Policy Ownership Borrowed Value
Applicant Co-Applicant
U.S. Gov't & Readily Marketable Securities (Sch. A1)Non-Readily Marketable Securities (Sch. A2)Accounts and Notes Receivable (Sch. B)
Life Insurance Loans (Sch. C)
Other Notes Payable (Sch. H)
Personal Mortgage Debt (Sch. E1)
Outstanding Taxes Payable
Number of Years Covered
TOTAL Schedule B:
TOTAL Schedule C:
TOTAL Schedule A1:
TOTAL Schedule A2:
Schedule C: Insurance (use additional sheet if necessary)
Schedule B: Accounts and Notes Receivable
Life Insurance Company BeneficiaryType of Policy
Monthly PaymentName of debtor Collateral
Monthly Distribution if Disabled
Disability Insurance
NON-READILY MARKETABLE SECURITIES (CLOSELY HELD, THINLY TRADED / OTC, OR RESTRICTED STOCK)(Sch. A2)
Total Liabilities and Net Worth
Description Owner(s) Where Held Cost
Schedule A: All Securities (Including non-money market Mutual Funds)
Total LiabilitiesNet Worth (Total Assets minus Total Liabilities)
IRA, 401(k), & Other Vested Retirement AccountsDeferred Income (Number of years deferred ______)Automobiles (Year, Make, Model):
Current Value
Cash on Hand and in Banks (Sch. G1)(Including Money Market Accounts and CDs)
Other Liabilities (Detail):
Total Assets
No. of Shares (Stock)
Assets Liabilities
Net Cash Surrender Value of Life Insurance (Sch. C)
READILY MARKETABLE SECURITIES (INCLUDING US GOVERNMENT AND MUNICIPALS)(Sch. A1)*
Residential Real Estate (Sch. D1)
Partnership / PC Interests (Sch. F)Real Estate Investments (Sch. D2)
Notes Due: Partnerships (Sch. F)Investment Mortgage Debt (Sch. E2)
Acc'ts Payable (Including Credit Cards) (Sch. G2)
Insurance Carrier
or Face Value (Bonds)
Personal Property:
Other Assets (detail):
Schedule D: Personal Residence & Real Estate Investments (majority ownership only)
Year
PercentageOwned Year
%%%%
Monthly Interest Loan Payment Rate Maturity
%%%
Monthly Interest Loan Payment Rate Maturity
%%%%
Date of Percent Final Contri-Investment Owned bution Date
%%%%
Stmt. Date Balance Stmt. Date Balance
Schedule H: Notes Payable
Amount of Secured Monthly Interest MaturityLine/Loan Yes/No Payment Rate Date
%%%%%
Total Schedule H:Total Monthly Pmts.
Schedule G: Cash on Hand/Accounts Payable*
Cost(Name)Type of Investment
Creditor (Name)
Schedule F: Partnerships (less than majority ownership for real estate partnerships)*
Total Loan Amount (Sch E2):
on NotesBalance DueCurrent Market
Value
Type of Account
Property Address
Schedule E: Personal Residence & Real Estate Mortgages (majority ownership only)
Investment PropertyTotal Loan Amount (Sch E1):
Present Loan Amount
*Note: For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investment or S-corporations, schedule K-1s.
UnpaidBalance
Personal Residence(s)
Property Address Lender Present Loan Amount
Due To
Lender
Total Schedule F:
Property Address
Total Market Value (Sch D2):
Total Cash on Hand (Sch. G1) Total Accounts Payable (Sch. G2)
Investment Property
Legal OwnerPurchase
Market ValuePrice
Total Market Value (Sch D1):
Market Value
Personal Residence(s)
Collateral
Property Address Legal OwnerPurchase
Price
1.) Are there any suits or legal actions pending against you?
2.) Have you, or Co-Applicant, ever been convicted of a felony?If Yes, provide details: ____________________________________________________________
3.) Have you (or either of you) or any firm in which you were a major owner everdeclared bankruptcy or settled any debts for less than the amount owed?
4.) Are you presently subject to any unsatisfied judgments or tax liens?
5.) Are any of your tax returns currently being audited or contested?
6.) Are any of your tax obligations past due?
7.) Do you pay alimony or child support?
8.) Do you receive alimony or child support, or separate maintenance income?*If yes, attach information.*PLEASE NOTE: Income from alimony, child support, or separate maintenance income need not be revealed if theapplicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.
9.) Do you have a line of credit or unused credit facility at any other institutions?If so, please indicate where, how much, and name of banker:_______________________________________________________________________________
10.) Do you expect any significant changes in your income, expenses, or financial conditionsover the next twelve months?
11.) Are (either of) you a guarantor, co-maker, or endorser for any debt of anindividual, corporation, or partnership?
12.) Are you contingently liable on any lease or contract?
Please answer the following questions:
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Representations and Warranties
___________________________________________________Applicant's Signature
___________________________________________________Co-Applicant's Signature(if the financial accommodation is being requested jointly)
__________________________________Date
__________________________________Date
Please keep a copy of this document for your records.
Notice: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), or because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Reserve Consumer Help Center, PO Box 1200, Minneapolis, MN 55480.
If the loan you are applying for is to be secured with a first mortgage on a dwelling, we may order an appraisal to determine the property’s value and charge you for this appraisal. We will promptly give you a copy of any appraisal, even if your loan does not close. You can pay for an additional appraisal for your own use at your own cost.
888.725.2207 www.norwaysavings.bank MEMBER FDIC
Thank you for completing your Personal Financial Statement!
Two options for submitting your completed PFS:
1. Fax, mail, or drop it off to your Norway Savings Bank commercial lender OR
2. Electronic Submission: Please contact your lender to request sending yourPFS via secure encrypted email and instructions for using the service. If youhave scanning capability, you can scan your signed document and attach it tothe reply of a secure message using our ZixCorp Message Service.
To protect the confidentiality of your information please DO NOT ATTACH your Personal Financial Statement to regular email.
For a list of commercial lenders, please visit: https://www.norwaysavings.bank/business-banking/business-loans/meet-the-commercial-team/
Your privacy is important to us! Emails are like postcards – everyone wants to read them! We welcome your emails, however, to protect your privacy never include personal information in your message unless you are using secure encrypted email. Thank you for banking with Norway Savings Bank!
PERSONAL FINANCIAL STATEMENT AS OF: _______________________
Title/Position: No. Years with Employer:
No. Years with Employer:Title/Position:
Name and Address of previous employer(if with current employer less than 3 years):
Title/Position: No. Years with Employer:
Name, Phone No. of your Accountant:
Name, Phone No. of your Attorney:
Name, Phone No. of your Investment Advisor/Broker:
Applicant Name:
Name & Address of previous employer (if with current employer less than 3 years):
Home Phone:
Title/Position: No. Years with Employer:
Cell Phone: Work Phone:
Address of Employer:
SUBMITTED TO: Norway Savings Bank
PERSONAL INFORMATION: (Applicant)
E-Mail Address:
Employer:
Name, Phone No. of your Insurance Advisor:
Home Address:
PERSONAL INFORMATION: (Co-Applicant)
Co-Applicant Name:
Home Phone: Cell Phone:
Date of Birth: Social Security No.:
Name, Phone No. of your Attorney:
Name, Phone No. of your Investment Advisor/Broker:
Name, Phone No. of your Insurance Advisor:
Name, Phone No. of your Accountant:
Home Address:
Address of Employer:
E-Mail Address:
Employer:
Date of Birth: Social Security No.:
Work Phone:
Balance Sheet as of __________________________Amount ($) Amount ($)
Pledged?
Yes / No
*If not enough space, attach a separate schedule or brokerage statement and enter totals only
Rate Maturity Unpaid Balance
%
%
%
Face Amount Amount Cash Surrender
of Policy Ownership Borrowed Value
Applicant Co-Applicant
U.S. Gov't & Readily Marketable Securities (Sch. A1)
Non-Readily Marketable Securities (Sch. A2)
Accounts and Notes Receivable (Sch. B)
Life Insurance Loans (Sch. C)
Other Notes Payable (Sch. H)
Personal Mortgage Debt (Sch. E1)
Outstanding Taxes Payable
Number of Years Covered
TOTAL Schedule B:
TOTAL Schedule C:
TOTAL Schedule A1:
TOTAL Schedule A2:
Schedule C: Insurance (use additional sheet if necessary)
Schedule B: Accounts and Notes Receivable
Life Insurance Company BeneficiaryType of Policy
Monthly PaymentName of debtor Collateral
Monthly Distribution if Disabled
Disability Insurance
NON-READILY MARKETABLE SECURITIES (CLOSELY HELD, THINLY TRADED / OTC, OR RESTRICTED STOCK)(Sch. A2)
Total Liabilities and Net Worth
Description Owner(s) Where Held Cost
Schedule A: All Securities (Including non-money market Mutual Funds)
Total LiabilitiesNet Worth (Total Assets minus Total Liabilities)
IRA, 401(k), & Other Vested Retirement Accounts
Deferred Income (Number of years deferred ______)
Automobiles (Year, Make, Model):
Current Value
Cash on Hand and in Banks (Sch. G1)
(Including Money Market Accounts and CDs)
Other Liabilities (Detail):
Total Assets
No. of Shares (Stock)
Assets Liabilities
Net Cash Surrender Value of Life Insurance (Sch. C)
READILY MARKETABLE SECURITIES (INCLUDING US GOVERNMENT AND MUNICIPALS)(Sch. A1)*
Residential Real Estate (Sch. D1)
Partnership / PC Interests (Sch. F)
Real Estate Investments (Sch. D2)
Notes Due: Partnerships (Sch. F)
Investment Mortgage Debt (Sch. E2)
Acc'ts Payable (Including Credit Cards) (Sch. G2)
Insurance Carrier
or Face Value (Bonds)
Personal Property:
Other Assets (detail):
Schedule D: Personal Residence & Real Estate Investments (majority ownership only)
Year
PercentageOwned Year
%%%%
Monthly Interest Loan Payment Rate Maturity
%%%
Monthly Interest Loan
Payment Rate Maturity
%%%%
Date of Percent Final Contri-
Investment Owned bution Date
%%%
%
Stmt. Date Balance Stmt. Date Balance
Schedule H: Notes Payable
Amount of Secured Monthly Interest MaturityLine/Loan Yes/No Payment Rate Date
%%%%%
Total Schedule H:Total Monthly Pmts.
Schedule G: Cash on Hand/Accounts Payable*
Cost(Name)
Type of Investment
Creditor (Name)
Schedule F: Partnerships (less than majority ownership for real estate partnerships)*
Total Loan Amount (Sch E2):
on Notes
Balance DueCurrent Market
Value
Type of Account
Property Address
Schedule E: Personal Residence & Real Estate Mortgages (majority ownership only)
Investment Property
Total Loan Amount (Sch E1):
Present Loan Amount
*Note: For investments which represent a material portion of your total assets, please include the relevant financial statements or tax returns, or in the case of partnership investment or S-corporations, schedule K-1s.
UnpaidBalance
Personal Residence(s)
Property Address Lender Present Loan Amount
Due To
Lender
Total Schedule F:
Property Address
Total Market Value (Sch D2):
Total Cash on Hand (Sch. G1) Total Accounts Payable (Sch. G2)
Investment Property
Legal OwnerPurchase
Market ValuePrice
Total Market Value (Sch D1):
Market Value
Personal Residence(s)
Collateral
Property Address Legal Owner
PurchasePrice
1.) Are there any suits or legal actions pending against you?
2.) Have you, or Co-Applicant, ever been convicted of a felony?If Yes, provide details: ____________________________________________________________
3.) Have you (or either of you) or any firm in which you were a major owner everdeclared bankruptcy or settled any debts for less than the amount owed?
4.) Are you presently subject to any unsatisfied judgments or tax liens?
5.) Are any of your tax returns currently being audited or contested?
6.) Are any of your tax obligations past due?
7.) Do you pay alimony or child support?
8.) Do you receive alimony or child support, or separate maintenance income?*If yes, attach information.*PLEASE NOTE: Income from alimony, child support, or separate maintenance income need not be revealed if the
applicant or co-applicant does not wish to have it considered as a basis for repaying this obligation.
9.) Do you have a line of credit or unused credit facility at any other institutions?If so, please indicate where, how much, and name of banker:_______________________________________________________________________________
10.) Do you expect any significant changes in your income, expenses, or financial conditionsover the next twelve months?
11.) Are (either of) you a guarantor, co-maker, or endorser for any debt of anindividual, corporation, or partnership?
12.) Are you contingently liable on any lease or contract?
Representations and Warranties
__________________________________ ___________________________________________________Date Applicant's Signature
__________________________________ ___________________________________________________Date Co-Applicant's Signature
(if the financial accommodation is being requested jointly)Please keep a copy of this document for your records.
Please answer the following questions:
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
The information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guarantee of the undersigned. The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct and complete. Each of the undersigned agrees to notify you immediately and in writing of any changes in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. If the undersigned fail to notify you as required above, or if any of the information herein should prove to be inaccurate or incomplete in any material respect, you may declare the indebtedness of the undersigned or the indebtedness guaranteed by the undersigned, as the case may be, immediately due and payable. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein and to determine the credit-worthiness of the undersigned. The undersigned authorize any person or consumer reporting agency to give you any information it may have on the undersigned. Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned. As long as any obligation or guarantee of the undersigned to you is
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
If Yes, provide details: ____________________________________________________________
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
