357 Roosevelt Road - Glen Ellyn
100 North Wheaton Avenue - Wheaton
370 South County Farm Road - Wheaton
 PERSONAL FINANCIAL STATEMENT
 
You are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested. Do not complete "Other Party Information."
You are applying for joint credit with a Co-Borrower this statement may be completed jointly by both married and unmarried Co-Borrowers if their assets and liabilities are sufficiently joined so that the statement can be meaningful and fairly presented on a combined basis. Complete all sections using the "Other Party Information" section for the Co-Borrower.
You are applying for individual credit, but are relying on income from alimony, child support, or separation maintenance of on the income of assets of another person as a basis for repayment of the credit requested. Complete all sections, providing information about the person in the "Other Party Information" section.
This statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporation(s). Do not complete "Other Party Information."
   
 Individual Information
  Borrower’s Name (include Jr. or Sr. if applicable)  
  Residence Address
  City
  State, Zip
  Position or Occupation
  Business Name
  Business Address
  City, State, Zip
  Home Phone (include area code) 
  Business Phone (include area code) 
     
 Other Party Information
  Co-Borrower’s Name (include Jr. or Sr. if applicable)
  Residence Address
  City
  State, Zip
  Position or Occupation
  Business Name
  Business Address
  City, State, Zip
  Home Phone (include area code) 
  Business Phone (include area code) 
     
 Assets Amount in Dollars
1. Cash - checking accounts Ownership
 2. Cash - savings accounts Ownership
3. Certificates of deposit Ownership
4. Securities - stocks / bonds / mutual funds:  
 
 Name of Security
Number of Shares
Cost ($)
Date of Acquisition
Market Value ($)
Ownership
       
Total
5. Notes & contracts held
 
 From Whom
Owing

Original
amount ($)
Original
Date

Monthly
payment ($)
Maturity
Date
History/
Purpose
Balance
Owing ($)
Ownership
           
Total
         
6. Life insurance (cash surrender value) 
Ownership
7. Personal property (autos, jewelry, etc.) 
Ownership
8. Retirement Funds (eg. IRAs, 401k) 
Ownership
9. Real estate (market value)    
 
 Description / Location
Amount Owing ($)
Original Cost ($)

Purchase Date

Market Value ($)
Ownership
       
Total
10. Stocks in Privately Held Companies  
 
 Company Name
Number of Shares
$ Invested
Est. Market Value ($)
Ownership
     
Total
11. Other assets (specify)    
 
Ownership
 
Ownership
     
 
 
Total Assets
  
       
 Liabilities Amount in Dollars
1. Current Debt (Credit cards, Accounts)  
 
 Name of Card / Creditor
Amount Due ($)
 
 
Total
2. Notes payable (describe below)   
 
 Name of Creditor
Original amount
($)
Monthly Payment
($)
Interest Rate
Secured by (Liens)
Amount Owing
($)
 
 
 
 
Total
3. Taxes payable  
4. Real estate mortgages (describe)   
 
 Name of Creditor
Original amount
($)
Monthly Payment
($)
Interest Rate
Secured by (Liens)
Amount Owing
($)
 
 
 
 
Total
5. Other liabilities (specify)
6. Other liabilities (specify)
   
Total Liabilities
       
   
Net Worth
       
 Statement of Income and Expenditures 
       
 Annual Income
Individual
Other Party
  Salary
  Securities Income
  Rentals
  Other (describe) I understand that I need not reveal income from alimony, child support or separate maintenance, unless I want the bank to consider it when evaluating this statement.
  1.
  2.
   Total Income
       
 Monthly Expenditures
  (excluding ordinary living expenses)
Individual
Other Party
 
Mortgage
 
Rent
 
Income Taxes
 
Insurance Premiums
 
Property Taxes
 
Alimony, child support or separate maintenance
 
Other (describe) Include installment payments other than real estate 
 
1.
 
2.
 
3.
  Total Expenditures
       
  Net Cash Income
(Exclusive of ordinary living expenses)
       
 
Contingent Liabilities (Debts on which I am or my spouse or comaker, guarantor or endorser and obligations which
either of us will have to pay, if the person primarily liable does not pay)
 
1.
 
2.
  Totals
       
  Please Provide
Name
Phone Number
(include area code)
  
  Attorney
 
  Accountant
 
  Financial Advisor
 
  Insurance
 
     
  Are you a partner or officer in any other venture? Yes No
  If so, describe:
  Are you obligated to pay alimony, child support or separate maintenance payments? Yes No
  If so, describe:  
  Are any assets pledged other than as described on schedules? Yes No
  If so, describe:  
  Have you ever been declared bankrupt? Yes No
  If so, describe:  
  Are you a defendant in any suite or legal actions? Yes No
         
  Personal bank accounts carried at
Account Numbers
  
 
Checking
 
Savings
 
Checking
 
Savings
       
 ACKNOWLEDGMENT AND AGREEMENT
By selecting the “Submit Application” button below, I/We certify and acknowledge the following  

1. I/We have read all applicable credit disclosures;
2. I/We applies for the loan indicated in this application to be secured by a mortgage on deed of trust on the property describe herein, and represents that the property will not be used for any illegal or restricted purpose;
3. I/We represent that all statements made on this application are true and made for the purpose of obtaining the loan;
4. The Lender may obtain verification from any source named in this application, the original or a copy of this application will be retained by the Lender, even if the loan is not granted;
5. I/We authorize the Lender to make any necessary credit investigation and answer questions about the Bank’s credit experience with me/us;
6. I/We understand that the Lender may request additional information including personal financial information from me during the application process.
7. I/We fully understand that it is a federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code, Section 1014.

Finally, I/we agree that the act of clicking the “Submit Application” button below will constitute your legally binding signature(s), and Community Bank Wheaton/Glen Ellyn will be entitled to rely on it as such for all purposes.

Yes, I/we certify and acknowledge that I/we have read the above information, the product terms and conditions, and all applicable legal disclosure information.
 
Print Application  
To apply, print this completed application and fax, mail or bring it to any of our locations.