:: NIBJ :: Personal Financial Statement ::

Please fill out the form properly and then click submit.

Name:
Employer:
Home Address:
Address:
Telephone no.:
Telephone no.:

 

I make the following statement of all my assets and liabilities as of the and give other material information for the purpose of obtaining credit with you on notes and bills bearing my signature, endorsement, or guarantee, and agree to notify you promptly of any change affecting my ability to pay.

 

ASSETS
$
LIABILITIES & NET WORTH
$
Cash (on hand)
Notes Payable to Banks, Unsecured
Ja. Government securities (bonds)
Notes Payable to Banks, Secured
Accounts & Loans Receivables
Notes Receivable, Discounted
Notes Receivables, Not discounted
Notes Payable to Others, Unsecured
Notes Receivables, Discounted
Notes Payable to Others, Secured
Life Insurance, Cash surrender value
Loans against Life Insurance
Other stocks and bonds
Accounts payable
Real Estate
Interest Payable
Automobiles
Taxes and Assessments payable
Mortgages payable on real estate
Other Assets (itemize)
Other liabilities (itemize)
Net Worth
Total Assets
Total liabilities and Net worth

 

:: Personal Information ::

Years with present employer:
Business occupation:
Name, address and Years with previous employer:
Partner of office:
Married: Dependent children:
Single: Other Dependents:
Previous Home Address:
Spouses Employer & Address
Name and Address of two References:
1. Tel.no.:
2. Tel.no.:
CONTINGENT LIABILITIES
$
GENERAL INFORMATION
As endorser or co-maker
Are any assets pledged?
On leases or contracts
Are you defendant in any suits or legal action? Are you defendant in any suits or legal action?
Legal claims
Have you ever made a composition settlement? Explain
Provisions for income tax
 
Other special dept.
Have you ever taken bankcruptcy? Explain
 

 

:: SUPPLEMENTARY SCHEDULES ::

  • NO.1 Banking Realations (A list of all my bank accounts including savings, and loans)
  • NO.1A Other financial relations, Credit Union, Building Society

 
Name and Location of Bank Cash Balance Amt. of Loan Maturity of Loan How endorsed, guaranteed, or secured
NO.2 Accounts, Loans, and Notes Receivable. (A list of the largest amounts owing to me.)
Name and Address of Debtor Amount Owing Age of Dept Description or nature of debt Description of security held Date payment expected
NO.3 Life Insurance
Name of person Name of beneficiary Name of Insurance co. Type of policy Face amount of policy Total cash surrender value Total loans against policy Amount of yearly premium Is policy assigned?
NO.4 Other Stocks & Bonds
Face value (bonds) No. of shares (stocks) Description of security Registered in name of Cost Present market value Income received last year To whom pledged
NO.5 Real Estate
Description or street no. Dimensions or acres Improvent consist of Mortgaes or liens Due Dates and amounts of payment Assessed value Present market Unpaid taxes: Year Unpaid taxes: Amount
NO.6 Summary of Monthly Income and Expenditure $
Income from: Salary
Rent mortgage
Income from: Real estate
Personal and other Bank Loans
Income from: Bonus and Commisions
Other loans
Income from: Dividends
Life insurance Premiums
Income from: Other sources
Living, Other expenses
Total
Total

 

The undersigned certifies that the information inserted herein have been carefully read and is true and correct.

 

 
National Investment Bank of Jamaica Ltd. copyright 2006