Private Lending Solutions

Personal Information

Full Name: Email Address: Social Security Number: Date of Birth: Home Address: Home Phone: Business Address: Business Phone: Employer: How Long (Employer): Occupation/Position: Spouse's Name: No. of Dependents:

Section A: Assets

Cash: Marketable Securities: Non-Marketable Securities: Investments in Partnerships: Real Estate (Homestead): Real Estate (Other): IRA & Retirement Plans: Oil & Gas Interests: Other Assets (Personal Property):

Section B: Liabilities

Mortgage Payable (Homestead): Real Estate Mortgage Payable: Notes Payable: Margin Debt (Brokers): Debt on Non-Marketable Securities: Loans Secured by Retirement: Oil & Gas Related Debt: Taxes Payable: Credit Card Debt: Other Liabilities:

Section C: Cash Income and Expense Information

Cash Income (This Year) Gross Wages or Salaries: Commissions, Bonuses, etc.: Partnership Draws, etc.: Partnership Distributions: Interest & Dividends: Rental Income: Oil & Gas Income: Other: Total Cash Income:

Cash Expense (This Year) Real Estate / Mortgage Payments: Regularly Scheduled Payments: Income Taxes: Partnership Contributions: Other Taxes (Real Estate, etc.): Living Expenses & Misc.: Rental Expenses: Oil & Gas Expenses: Other Anticipated Payments: Other: Total Cash Expense:

Net Cash Flow:

Schedules

Schedule 1 – Cash

Account Name: Bank Name & Address: Balance: Type / Number: Pledged?

Schedule 2 – Marketable Securities (Stocks, Bonds, Gov't Issues, Mutual Funds, etc.)

Description of Securities: Face or # Shares: Market Value: Pledged? Margin Debt: Yearly Income:

Schedule 3 – Non-Marketable Securities

Description of Securities: Face or # Shares: Market Value: Pledged? Debt: Cost:

Schedule 4 – Investments in Partnerships

Partnership Name: General / Limited: Percent Owned: Cost: Market Value: Debt: Annual Payments: Annual Distributions: Annual Contributions:

Schedule 5 – Real Estate

Location: Percent Owned: Cost: Market Value: Debt: Lienholder: Annual Payments: Annual Income: Annual Expense:

Schedule 6 – IRA's & Retirement Plans

Type: % Vested: Balance: Debt: Net Value:

Schedule 7 – Oil & Gas Interests

Type of Interest: Percent Owned: Value: Debt: Lienholder: Annual Payments: Annual Income: Annual Expense:

Schedule 8 – Notes Payable

Fin. Institution: Purpose: Original Date: Original Balance: Current Balance: Maturity: Annual Payments: Collateral:

Schedule 9 – Contingent Obligations

Instructions: State total amount by type of liability and describe below.

A) As Guarantor or Endorser: $ B) On Leases or Contracts: $ C) For Legal Claims or Judgements: $ D) Income Tax Claim or Dispute: $ E) Letters of Credit: $ F) Future Capital Contributions: $ G) Other: $ Total of A–G:

Describe A–G Above: Beneficiary Party: Amount Obligated: Date Obligated: Purpose or Explanation: Maturity:

Schedule 10 – Insurance

AUTO

Insurance Co.: Policy No.: Coverage: Agent Name: Phone #:

HOME / REAL ESTATE

Insurance Co.: Policy No.: Coverage: Agent Name: Phone #:

LIFE

Insurance Co.: Policy No.: Coverage: Face Value: Cash Value: Agent Name: Phone #:

Legal and Certification Questions

1) Are you a defendant in any suits or legal actions?

No Yes

2) Are any returns being audited or contested?

No Yes

3) Have you drawn a will?

No Yes

4) Do you have a line of credit or unused line of credit at any other institution?

No Yes

5) Have you ever filed a petition in bankruptcy or has one been filed involuntarily against you?

No Yes

6) Are you an Executive Officer, Director, or Principal Shareholder of a bank?

No Yes

Legal Disclosure & Consent

By submitting this financial statement and any accompanying documentation, I affirm that the information provided is accurate, complete, and reflects my financial position as of the date specified. I understand that this information will be used by the institution for the purpose of evaluating my creditworthiness and making financial decisions.

I authorize the institution to verify any and all information contained herein, including but not limited to liabilities, income, credit history, and contingent obligations. This may involve obtaining credit reports, contacting third-party institutions, and requesting additional documentation as necessary. I further consent to the institution's ongoing access to my credit report for the purpose of reviewing or updating this financial profile.

I acknowledge that misrepresentation, falsification, or the withholding of material information may result in the rejection of this application, the cancellation of any agreement made, and possible legal consequences under applicable laws, including federal statutes governing fraud (18 USC Section 1014).

I hereby declare that I have read and understand this disclosure, and that my submission of this form constitutes my legal consent to the terms stated herein.

Typed Name (Signature): Date:

Personal Information

Section A: Assets

Section B: Liabilities

Section C: Cash Income and Expense Information

Schedules

AUTO

HOME / REAL ESTATE

LIFE

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