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["Kotula Group",{"$nulls":10},"PERSONAL FINANCIAL STATEMENT",null,null,0]
["220 N. Green Street",{"$nulls":10},"nasbp.org/toolkit",null,null,0]
[{"$nulls":14}," and "]
["Chicago, IL 60607"]
["Phone: (312) 895-4565"]
["Web: http://www.kotulagroup.com",{"$nulls":7},"Date Prepared:"]
[]
["SECTION 1: PERSONAL INFORMATION"]
[]
["Full Name:",{"$nulls":4},"         Date of Birth:",null,"MM/DD/YY",null,"    SSN:","###-##-####"]
[]
["Spouse Name:",{"$nulls":4},"         Date of Birth:",null,"MM/DD/YY",null,"    SSN:","###-##-####"]
[]
["Address:",{"$nulls":4},"         Business Name:"]
[]
["City, State, Zip:",{"$nulls":4},"         Home Phone:",null,"###-###-####",null,"Alt. Phone:","###-###-####"]
["NOTE: Complete Schedules A-H prior to completing Section 2."]
["SECTION 2: STATEMENT OF FINANCIAL CONDITION AS OF"]
["Assets: (Do not include assets of doubtful value)",null,null,null,"In Dollars (omit cents)",null,null,"Liabilities:",null,null,"In Dollars (omit cents)"]
["Cash in Primary Bank: (checking & savings)",{"$nulls":6},"Unsecured Debt: (Sch. G)",null,null,0]
[]
["Cash & CD's in Other Banks: (Sch. A)",null,null,null,0,null,null,"Current Bills Due:"]
[]
["Stock Bonds & Marketable Securities: (Sch. B)",null,null,null,0]
[]
["Real Estate Owned: (Sch. C)",null,null,null,0,null,null,"Real Estate Mortgages: (Sch. C)",null,null,0]
[]
["Cash Surrender: (Sch. D)",null,null,null,0]
[]
["Business Ventures: (Sch. E)",null,null,null,0,null,null,"Secured Debt (Sch. H):",null,null,0]
[]
["Notes Receivable: (Sch. F)",null,null,null,0,null,null," (other than real estate) "]
[]
["Personal Property: (jewelery, coins, collections, etc.)",{"$nulls":6},"Taxes Payable:"]
[]
["Automobiles, RV's, Boats:",{"$nulls":6},"Other Debts & Liabilities: (specify)"]
[]
["Other Assets: (specify)"]
{"$rows_empty":7}
["TOTAL ASSETS:",null,null,null,0,null,null,"TOTAL LIABILITIES:",null,null,0]
[]
[{"$nulls":7},"TOTAL NET WORTH:",null,null,0]
[]
[{"$nulls":7},"TOTAL LIABILITIES & NET WORTH:",null,null,0]
[]
["Do you have a will?"]
[]
["Have you ever declared bankruptcy?"]
[]
["Accountant Name:",null,null,null,"Address:",{"$nulls":4},"Phone:"]
[]
["Attorney Name:",null,null,null,"Address:",{"$nulls":4},"Phone:","###-###-####"]
[]
["Do you have any…",{"$nulls":7},"If \"yes\" to any questions, describe:"]
[]
["     contingent liabilities?",{"$nulls":4},"Est. Amount:"]
[]
["     involvement in pending legal actions?",{"$nulls":4},"Est. Amount:"]
[]
["     other special circumstances?",{"$nulls":4},"Est. Amount:"]
[]
["     contested income tax liens?",{"$nulls":4},"Est. Amount:"]
[]
["SCHEDULE A: CASH AND CD'S IN OTHER BANKS"]
["Description:",null,null,"Name of Institution:",null,null,"In Name of:",null,"Pledged or Held by Others?",null,"Value:"]
{"$rows_empty":8}
["SCHEDULE B: STOCKS, BONDS, MARKETABLE SECURITIES"]
["BROKERAGE ACCOUNTS"]
["Name of Brokerage:",null,null,null,"In Name of:",null,"Pledged or Held by:",null,"Cost:",null,"Market Value:"]
{"$rows_empty":8}
["INDIVIDUAL SECURITIES NOT INCLUDED ABOVE (INCLUDE IRA AND 401K ACCOUNTS)"]
["# of Shares or Face Value:","Individual Securities:",null,null,"In Name of:",null,"Pledged or Held by:",null,"Cost:","Market Value:",null,"Retirement Account:"]
{"$rows_empty":10}
["SCHEDULE C: RESIDENCE AND OTHER REAL ESTATE"]
["Address and Type of Property:",null,null,"Title in Name of:",null,"Percentage Owned:","Year Acquired:","Cost:","Market   Value:","Monthly Payment:","Mortgage Balance:","Maturity   Year:"]
{"$rows_empty":10}
["SCHEDULE D: LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE"]
["Name of Insurance Company:",null,"Owner of Policy:",null,"Name of Insured:",null,"Beneficiary and Relationship:",null,null,"Face Amount:","Policy Loans:","Cash Surrender:"]
{"$rows_empty":15}
["SCHEDULE E: BUSINESS VENTURES AND OTHER ASSETS"]
["Name of Business:",null,null,"Type of Business:",null,null,"Years in Business:","Net Worth:",null,"Percentage Owned:","Value of your Ownership Interest:"]
[{"$nulls":10},0]
[]
[{"$nulls":10},0]
[]
[{"$nulls":10},0]
[]
[{"$nulls":10},0]
[]
["SCHEDULE F: NOTES RECEIVABLE"]
["Due From:",null,null,"Due Date:",null,"Description",null,null,"Monthly Payment:",null,"Total Amount:"]
{"$rows_empty":8}
["SCHEDULE G: UNSECURED DEBT (CREDIT CARDS, ETC.)"]
["Name of Creditor:",null,null,"Description of Debt:",null,"Describe:",null,null,"Monthly Payment:",null,"Amount Owed:"]
[]
["Total of All Credit Cards",{"$nulls":4},"Various credit card debt"]
{"$rows_empty":7}
["SCHEDULE H: SECURED DEBT (HELOC, VEHICLES, ETC.)"]
["Name of Creditor:",null,"Original Loan/Line Amount:",null,"Date of Loan:","Maturity Date:","Unsecured or Secured (List Collateral)",null,null,"Monthly Payment:","Amount Owed:"]
{"$rows_empty":12}
["This information contained in this statement is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the surety of the undersigned. The undersigned acknowledge and understand that you are relying on the information provided herein in deciding to grant or continue credit or to accept a surety thereof.  Each of the undersigned represents, warrants, and certifies that the information provided herein is true, correct and complete.  Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change (1) in any of the information contained in this statement or (2) in the financial condition of any of the undersigned or (3) in the ability of any of the undersigned to perform its (or their) obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct.  You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein, and to determine the credit-worthiness of the undersigned.  Each of the undersigned authorizes you to answer questions about your credit experience with the undersigned. "]
[]
[]
["Signature (applicant)",{"$nulls":5},"Date signed"]
[null,null,0]
[]
[]
[]
["Signature (co-applicant)",{"$nulls":5},"Date signed"]
[null,null,0]