W.B.A.                   127 (2/07)                  11031                                                                 
2007 Wisconsin Bankers Association / Distributed by FIPCO®
INDIVIDUAL FINANCIAL STATEMENT
IMPORTANT: Date and sign statement 
(For Wisconsin residents only)
Date of Financial Statement      
Name       
Address       
To       	(“Lender”)
For the purpose of obtaining credit from Lender and any future credit granted by Lender, or to support the extension of credit already given, I make the following statement to Lender of my financial condition on      	. This statement is Lender's property.
For Wisconsin residents only: I am    married    unmarried    legally separated
Name of spouse       	Address      
NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under § 766.59, Wis. Stats., or court decree under § 766.70, Wis. Stats., adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted or an open-end credit plan is entered into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision.
INSTRUCTIONS FOR INFORMATION TO BE SUPPLIED BELOW:
 Individual Credit. If a married applicant is applying for individual credit, complete this statement including all marital property and all individual property of the applicant, but do not include individual property of the non-applicant spouse. Include all liabilities of both spouses. Only the applicant must sign on page 2.
 Joint Credit with spouse as joint applicant. If married applicants are applying for joint credit, include all assets and all liabilities of both spouses. Both spouses must sign this statement. 
 Joint Credit with                                                                              as joint applicant who is not your spouse. If a married applicant is applying for joint credit with someone other than his or her spouse, each applicant must complete a separate statement as if applying for individual credit, including all marital property and all individual property of the applicant. Do not include any individual property of the non-applicant spouse. Include all liabilities of the applicant and the applicant’s spouse. Only the applicant must sign on page 2.
For purposes of this statement:
Marital property means assets acquired with my or my spouse's income on or after 1-1-86; and
Individual property means property owned (whether in joint or sole name) by me prior to marriage, prior to establishing residence in Wisconsin, or prior to 1-1-86, however acquired, and property acquired by me by gift or inheritance at any time.
COMPLETE ALL BLANKS, WRITING “NO” OR “NONE” WHERE NECESSARY
ASSETS		LIABILITIES OF APPLICANT AND SPOUSE		
Cash on Hand and in Financial Institutions (Schedule A)	$           	Notes Payable – Lenders/Secured (Schedule E)	$           	
Gov’t and Listed Securities (Schedule B)	             	Notes Payable – Lenders/Unsecured (Schedule E)	             	
Unlisted Securities (Schedule B)	             	Notes Payable Others (Schedule E)	             	
Notes and Loans Receivable (Schedule F)	             	Life Insurance Loans (Schedule C)	             	
Homestead and Real Estate Owned (Schedule D)	             	Due to Brokers	             	
Automobiles	             	Accounts Payable	             	
Other Personal Property	             	Unpaid Income Taxes	             	
Cash Value Life Insurance (Schedule C)	             	Real Estate Mortgage Payable (Schedule D)	             	
Securities Held by Brokers in Margin Accts.	             	Real Estate Taxes	             	
Equity in Partnership	             	Credit Cards	             	
Equity in Proprietorship	             	Other Debts (Itemize Below)	             	
Vested Pension Benefits or Profit Sharing	             	     	             	
Other Assets: (Itemize Below)	             	     	             	
     	             	     	             	
     	             	     	             	
     	             	     	             	
     	             	     	             	
     	             	Total Liabilities	             	
     	             	Assets less Liabilities = Net Worth	             	
TOTAL ASSETS	$           	TOTAL LIABILITIES and NET WORTH	$           	
SOURCES OF INCOME FOR YEAR ENDED	CONTINGENT LIABILITIES OF APPLICANT AND SPOUSE	
Salaries & Bonuses*	$           	As Endorser, Co-Maker, or Guarantor	$           	
     	$           	On Lease or Contracts	$           	
Commissions	$           	Legal Claims	$           	
Dividends & Interest	$           	Other (describe)       	$           	
Real Estate	$           	     	             	
Other**      	             	     	             	
     	             	     	             	
*For Married Wisconsin residents, name each spouse and include the income of each spouse.
**Income from Alimony, Child Support or Separate Maintenance income and income from medical insurance, disability or wage continuation insurance need not be revealed if you do not wish the Lender to consider this income in determining your creditworthiness.
PERSONAL INFORMATION	
Home Telephone       	Social Security No.      	
Employer(s) of Applicant(s)       	
Are any assets pledged or restricted other than indicated on the following schedules? If so, describe.       	
Are you a defendant in any legal actions or suits? If so, describe.      	
Are you a partner or officer in any other venture? If so, describe.      	
Do you have a will?   Yes   No       If so, name of Personal Representative.       	
Have you ever been declared Bankrupt? If so, describe.       	
Date of Birth      	Driver’s License No. and State      	
COMPLETE SCHEDULES AND SIGN ON PAGE 2
Schedule A – Cash, Checking Accounts, Savings Accounts, & Certificates of Deposit
Type	Name of Financial Institution	Amount	In Name Of:	PLEDGED
YES    NO	
     	     	     	     			
     	     	     	     			
     	     	     	     			
     	     	     	     			
     	     	     	     			

Schedule B – U.S. Government, Listed & Unlisted Securities (List on separate sheet if necessary)
No. of Shares or Face Value (Of Bonds)	Description*	Owner	Market Value	PLEDGED
YES    NO	
     	     	     	     			
     	     	     	     			
     	     	     	     			
     	     	     	     			
     	     	     	     			
*Indicates if Securities are Restricted By Contract or SEC Regulations.
Schedule C – Life Insurance Carried, Include Group
Face Amount	Name of Company	Owner	Beneficiary	CASH SURRENDER
   Value         Loans	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	
     	     	     	     	     	     	

Schedule D – Real Estate Owned
Address & Type of Property	Date Acquired	Owner	Cost	Mkt. Value	MORTGAGE
Amount     Monthly $   Maturity	Insurance 	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	     	

Schedule E – Names of Banks or Other Lenders Where Credit Has Been Obtained
Name & Address of Lender	Borrower	Date Made	Monthly
Payment	Due	High Credit	Current Balance	Sec. or Unsec.	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	

Schedule F – Notes and Loans Receivable
Unpaid Amount	Name of Maker	Date Made	Security Pledged	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
NOTICE: We may report information about your account to credit bureaus. Late payments, missed payments, or other defaults on your account may be reflected in your credit report.
I certify that this financial statement is true and complete.  I authorize Lender or its agents to verify the information obtained in this statement and to obtain additional information concerning my financial condition, including, without limitation, consumer credit reports, although Lender may rely on this financial statement without any further verification.  I authorize Lender to furnish such information and any other credit experiences with me to others and to answer any questions about my credit experience and other financial relationships with Lender, to the extent not prohibited by applicable law. I agree to notify Lender, in writing, of any change that materially affects the accuracy of this statement.  Lender may share information bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living with its affiliates unless (1) I direct Lender at the address above that such information is unrelated to my transactions or experiences with Lender, and may not be shared by Lender with its affiliates, (2) the information constitutes "medical information" as defined under applicable federal law, or (3) the information when provided to an affiliate would constitute a "consumer report" under applicable federal law.

It may be a crime punishable by a fine or imprisonment or both to knowingly make false statements concerning any of the above information, under provisions of applicable federal and state law.

     	X
	(Date Signed)	Applicant Signature

							        X
	Joint Applicant Spouse Signature (joint credit only)
For married Wisconsin resident.  I understand Lender may be required by law to give notice of any credit transaction to my spouse.  The credit applied for, if granted, will be incurred in the interest of my marriage or family.

							        X				
	Applicant Signature