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["                    PERSONAL FINANCIAL STATEMENT"]
[null,null,null,null,null,null,null,null,null,null,"United Bank of Union                P.O. Box 500                    Union, MO 63084-0500              (636) 583-2555 www.ubu.bank"]
[]
["Submitted To: United Bank of Union",null,null,null,null,null,"Date:"]
[]
["Instructions for Filling Out This Form"]
["1). This form is made up of three tabs. Please be sure to open each tab and complete in its entirety. "]
["2). Print this form to sign and date, and return to your loan officer. "]
["3). Please contact us with any questions. "]
[]
["IMPORTANT:  Read these directions before completing this Statement"]
[]
["If you are applying for individual credit in your own name and are relying on your own income, or assets and not the income of assets of another person as the basis for repayment of the credit requested, or if this statement relates to your guaranty of the indebtedness of other person(s), firm(s), or corporation(s), complete only Sections 1, 3, and 4.  "]
[]
[]
["If you are applying for individual credit but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as basis for repayment of the credit requested , complete all sections. Provide information in Section 2 about the person whose alimony, support, or maintenance payments or income or assets you are relying on. Alimony, child support, or separate maintenance income, need not be revealed if you do not wish to have it considered as basis for repaying this obligation. "]
[]
[]
["Section 1 - Individual Information (type or print)",null,null,null,null,"Section 2 - Other Party Information (type or print)"]
["Name",null,null,null,null,"Name"]
["Address",null,null,null,null,"Address"]
["City, State & Zip",null,null,null,null,"City, State & Zip"]
["Social Security #",null,null,null,null,"Social Security #"]
["Date of Birth",null,null,null,null,"Date of Birth"]
["Position or Occupation",null,null,null,null,"Position or Occupation"]
["Business Name",null,null,null,null,"Business Name"]
["Business Address",null,null,null,null,"Business Address"]
["City, State & Zip",null,null,null,null,"City, State & Zip"]
["Length at present address",null,null,null,null,"Length at present address"]
["Length of employment",null,null,null,null,"Length of employment"]
["Resident Phone Number",null,null,null,null,"Resident Phone Number"]
["Business Phone Number",null,null,null,null,"Business Phone Number"]
["Have (either of) you or any firm in which you were a major owner ever declared bankruptcy, or settled any debts for less than the amounts owed?  If yes please provide details on a separate sheet.  "]
[null,null,null,null,null,null,"Yes","No"]
["Are (either of) you a defendant in any suit or legal action?",null,null,null,null,null,"Yes","No"]
["Are (either of) you presently subject to any unsatisfied judgements to tax liens?",null,null,null,null,null,"Yes","No"]
["When, if ever, have (either of) you been audited by IRS?",null,null,null,null,"Date:"]
[null,null,null,null,null,null,"( xx/xx/xxxx )"]
[]
["Section 3 - Statement of Financial Condition as of (insert date):"]
[null,null,null,"( xx/xx/20xx )"]
["Assets",null,"In dollars",null,null,"Liabilities",null,null,null,"In dollars"]
["(Do Not Include Assets of Doubtful Value)",null,"(omit cents)",null,"If Joint,",null,null,null,null,"Omit Cents",null,"If Joint,"]
[null,null,"[Individual]","[Joint]","with whom",null,null,null,null,"[Individual]","[Joint]","with whom"]
["Cash, Checking, Savings, CDs - see Schedule A",null,null,null,null,"Notes Payable to Banks & Others - see Schedule H"]
["U.S. Govt & Marketable Securities - see Schedule B",null,null,null,null,"Due to Brokers"]
["Non-Marketable Securities - see Schedule C",null,null,null,null,"Amounts payable to others - secured"]
["Securities held by broker in margin accounts",null,null,null,null,"Amounts payable to others - unsecured"]
["Restricted, control, or margin account stocks",null,null,null,null,"Accounts & Bills due "]
["Real Estate Owned - see Schedule D",null,null,null,null,"Unpaid income tax"]
["Accounts, Loans, & Notes Receivable",null,null,null,null,"Other unpaid taxes & interest"]
["Automobiles",null,null,null,null,"Real Estate Mortgages payable - see Schedules D & H"]
["Cash Surrender Value-Life Insurance - see Schedule E"]
["Vested Interest In Deferred Compensation / Profit-Sharing Plans - see Schedule F"]
["Business Ventures - see Schedule G"]
["Other Assets / Personal Property Itemize - see Schedule G if applicable"]
[null,null,null,null,null,"Total Liabilities",null,null,null,{"$f":"SUM(J45:J56)","v":0},{"$f":"SUM(K45:K56)","v":0},{"$f":"SUM(L45:L56)","v":0}]
[null,null,null,null,null,"Net Worth",null,null,null,{"$f":"C59-J57","v":0},{"$f":"D59-K57","v":0},{"$f":"E59-L57","v":0}]
["Total Assets",null,{"$f":"SUM(C45:C58)","v":0},{"$f":"SUM(D45:D58)","v":0},{"$f":"SUM(E45:E58)","v":0},"Total Liabilities and Net Worth",null,null,null,{"$f":"SUM(J57:J58)","v":0},{"$f":"SUM(K57:K58)","v":0},{"$f":"SUM(L57:L58)","v":0}]
[]
[]
["Section 4 - Annual Income For Year Ended as of    (insert date):         "]
[null,null,null,"( xx/xx/20xx )"]
["Annual Income","[Individual]","[Joint]","Annual Expenditures",null,"[Individual]","[Joint]","Contingent Liabilities Estimated Amounts",null,null,"[Individual]","[Joint]"]
["Salary, bonuses & commissions",null,null,"Mortgage / Rental Payments",null,null,null,"Do you have any…",null,"   Yes   No"]
["Dividends & Interest",null,null,"Real Estate Taxes & Assessments",null,null,null,"Contingent Liabilities (as endorser, co-maker or guarantor?)…"]
["Real Estate Income",null,null,"Taxes - federal, state & local",null,null,null,"Contingent liabilities on leases or contracts?"]
["Other Income",null,null,"Insurance Payments",null,null,null,"Involvement in pending legal actions?"]
["(Alimony, child support,  or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)",null,null,"Other Contract Payments (car payments, charge cards, etc.)",null,null,null,"Contested Income Tax liens?"]
[null,null,null,"Alimony, Child Support, maintenance",null,null,null,"Any estimated capital gains tax on the unrealized asset appreciation?"]
[null,null,null,"Other Expenses",null,null,null,"Other special debt or circumstances?"]
["Total Income",{"$f":"SUM(B65:B71)","v":0},{"$f":"SUM(C65:C71)","v":0},"Total Expenditures",null,{"$f":"SUM(F65:F71)","v":0},{"$f":"SUM(G65:G71)","v":0},"If \"yes\" to any question(s) describe:"]
[]
[]
[null,null,null,null,null,null,null,"Total Contingent Liabilities",null,null,{"$f":"SUM(K65:K74)","v":0},{"$f":"SUM(L65:L74)","v":0}]
["(COMPLETE SCHEDULES AND SIGN ON PAGE 2)"]

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[]
["SCHEDULE A - CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSITS, MONEY MARKET FUNDS, ETC."]
["Name of Financial Institution",null,null,"Type of Account","Owner",null,null,null,"(J)","If Pledged, to Whom?",null,null,"Balance"]
[]
[]
[]
[]
["SCHEDULE B - U.S. GOVERNMENT & MARKETABLE SECURITIES  (Use additional sheet if necessary)"]
["Number of Shares or",null,null,null,null,null,null,null,"Are these Registered,",null,"Market Value",null,"Exchanges Where Traded"]
["Face Value of Bonds",null,"Description",null,"In Name of",null,null,null,"Pledged, or Held by Others?"]
[]
[]
[]
[]
["SCHEDULE C - NON-MARKETABLE SECURITIES  (Use additional sheet if necessary)"]
["Number ",null,null,null,null,null,null,null,"Are these Registered,",null,"Value",null,"Method of Valuation"]
["of Shares",null,"Description",null,"In Name of",null,null,null,"Pledged, or Held by Others?"]
[]
[]
[]
[]
["SCHEDULE D - INVESTMENTS IN REAL ESTATE   (Use additional sheets if necessary)"]
["Description / Location",null,null,null,null,"%","Market Value",null,null,null,null,null,"Mortgage"]
["of Real Estate",null,null,"Date of Original",null,"Owned","of Your %",null,null,"Present",null,"Monthly","Maturity",null,"Mortgage"]
["Investment",null,"(J)","Investment / Amount",null,"By You","Of Investment",null,null,"Balance",null,"Payment","Date",null,"Owed To"]
[]
[]
[]
[]
["SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE"]
["Name of",null,"Owner",null,"Beneficiary",null,null,null,"Face",null,null,"Policy",null,"Cash"]
["Insurance Company",null,"of Policy",null,"and Relationship",null,null,null,"Amount",null,null,"Loans",null,"Surrender Value"]
[]
[]
[]
[]
["SCHEDULE F - VESTED INTEREST IN DEFERRED COMPENSATION / PROFIT-SHARING PLANS"]
["%",null,null,null,"Account",null,null,"Manner of Payout",null,"Distribution"]
["Vested","Company Name",null,null,"Number",null,null,"(Annuity, Lump Sum, etc.)",null,"Date",null,"Beneficiary",null,null,null,"Amount"]
[]
[]
[]
[]
["SCHEDULE G - BUSINESS VENTURES (Use additional sheets if necessary)"]
["List Name and Address",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Present"]
["of Any Business Venture",null,"Your Position /",null,"Line of",null,null,"Years","Total Assets",null,null,"Your % of","Net Worth",null,null,"Net Value"]
["In Which You Are",null,"Title In",null,"Business",null,null,"In","Listed in",null,null,"Ownership","Of Business",null,null,"of Your "]
["a Principal or Partner",null,"the Business",null,null,null,null,"Business","Section 3",null,null,null,null,null,null,"Investment"]
[]
[]
[]
[]
["SCHEDULE H - LOANS OWING BANKS, BROKERS, FINANCE COMPANIES, AND OTHERS (MASTERCARD, VISA, ETC.)"]
["Owing to",null,null,"Date of Original",null,"Present",null,null,"Monthly",null,"Date of"]
["(Acct. No.)",null,"(J)","Borrowing / Amount",null,"Balance",null,"Due","Payment",null,"Final Payment",null,"Secured by"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["Signature (individual)",null,null,null,null,null,null,null,null,"Date signed",null,null,null,","]
[]
["Signature (other party)",null,null,null,null,null,null,null,null,"Date signed",null,null,null,","]