NAME(S):      

ADDRESS:      

SOCIAL SECURITY #:      

TELEPHONE:       DATE:

FILL ALL BLANKS, WRITING “NO” OR “NONE” WHERE NECESSARY TO COMPLETE INFORMATION. USE AN
ADDITIONAL SHEET IF NEEDED.

ASSETS LIABILITIES

Cash in Banks       Notes Payable

     
Savings & Loan       To Banks

Earnest Money Deposited       To Relatives      

Investments: Bonds & Stocks To Others      

     
– See Schedule Installment Accounts Payable:
     
Investment in Own Business       Automobile

Accounts and Notes Receivable       Other      

Real Estate Owned – See Schedule       Other Accounts Payable      
Year Make Mortgages Payable on Real
           
Automobiles: Estate – See Schedule
Personal Property & Furniture       Unpaid Real Estate Taxes      

Life Insurance ($          ) Unpaid Income Taxes      

     
Cash Surrender Value Chattel Mortgages      
Other Assets – Itemize       Loans on Life Insurance Policies
     
            (Include Premium Advances)

            Other Debts – Itemize      

                 
                 
            TOTAL LIABILITIES      
            NET WORTH      
TOTAL ASSETS       TOTAL LIABILITIES & NET WORTH      

SOURCE OF INCOME PERSONAL INFORMATION

Base Salary $      OCCUPATION OR TYPE BUSINESS

     
Overtime Wages $     
EMPLOYER
Bonus and Commissions $     
     
Dividends and Interest Income $     
Real Estate Income (Net) $      Position held:       No. of years      
PARTNER OR OFFICER IN ANY OTHER VENTURE OR EMPLOYMENT
Spouse’s Income $     
     
Other Income – Itemize $     
     

Married Unmarried Separated Children (ages)

TOTAL $     
Age       Age of Spouse       Other Dependents      

CONTINGENT LIABILITIES GENERAL INFORMATION

As Endorser or Co-maker on Notes $      PERSONAL BANK ACCOUNTS CARRIED AT

     
Alimony Payments (Annual) $     
SAVINGS AND LOAN ACCOUNT AT
Are you defendant in any legal action? YES NO
     
Are there any unsatisfied judgments? YES NO
HAVE YOU EVER TAKEN BANKRUPTCY? EXPLAIN: YES NO PURPOSE OF LOAN
           

– COMPLETE ALL SCHEDULES AND SIGN ON SECOND PAGE –

COMPLETE THE FOLLOWING SCHEDULES IN DETAIL

PFS-2014 (Rev 9/9/03) 1

 SCHEDULE OF BONDS AND STOCKS

NON-MARKETABLE (UNLISTED
MARKETABLE ACTUAL
AMOUNT OR SECURITIES)
DESCRIPTION (Insert Valuation in Proper Column) MARKET
NO. SHARES ESTIMATED
VALUE
WORTH

                       

                       

                       

                       

                       

SCHEDULE OF REAL ESTATE

MORTGAGE
DESCRIPTION AND LOCATION ACTUAL MARKET VALUE
AMOUNT MATURITY DATE

                       

                       

                       

                       

                       

SCHEDULE OF NOTES PAYABLE

Specify any assets pledged as collateral, indicating the liabilities which they secure:

TO WHOM PAYABLE DATE AMOUNT DUE INTEREST ASSETS PLEDGED AS SECURITY

                                   

                                   

                                   

                                   

                                   

SCHEDULE OF INSTALLMENT ACCOUNTS

PROPERTY PURCHASED AMOUNT OWED MONTHLY PAYMENT

                 

                 

                 

                 

For the purpose of establishing credit responsibility, the following representations are submitted as being a true and accurate statement of
the financial condition of the undersigned on the       day of      , 20     .

By signing below, I (we), the undersigned, hereby authorize CB Richard Ellis, Inc. to obtain a credit report and to verify information
as needed.

Signature       Date       , 20      

Signature       Date       , 20      

NAME OF BROKER MAKING CREDIT AUTHORIZATION REQUEST:     

PHONE:      

PFS-2014 (Rev 9/9/03) 2