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                              PERSONAL STATEMENT
                         LEASE/FINANCING INFORMATION

                                                        SOC. SEC. #_________________
                                                        SPOUCE FIRST NAME___________
                                                        HOME PHONE__________________

Name:__________________________ Address_____________________________________________

For the purposes of procuring and maintaining credit from time to time in any form
whatsoever with the above named bank, for claims and demands against the undersigned
the undersigned submits the following as being a true and accurate statement of his
financial condition on the following date, and agree that if any change occurs that
materially reduces the means or ability of the undersigned to pay all claims or
demands against him, the undersigned will immediately and without delay notify the
said Bank, and unless the Bank is so notified it may continue to rely upon the
statement herein given as a true and accurate statement of the financial condition
of the undersigned as the close of business.

 Month:______________________________________________ Day:______________ 19_______
* For items marked with asterisk see also separate schedule below.
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                ASSETS                                 LIABILITIES               
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 Cash on hand and in Banks             Notes payable to Banks              
                                       Secured                             
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*U.S. Govt. Securities                 Notes payable to Banks              
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*Listed Securities                     Notes payable to                    
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*Unlisted Securities                   Notes payable to ohters             
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 Accounts & Notes                      Accounts and bills due              
 receivable - Due from                Ķ
 relatives & friends                   Unpaid Income tax                   
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 Accounts and Notes                    Other unpaind tax and               
 Receivable - Due from                 interests                           
 others - Good                                                             
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 Accounts and Notes                   *Real Estate Mortgages               
 receivable - Doubtful                 Payable                             
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*Real Estate Owned                     Chattel Mortgages and               
                                       other Leins payable                 
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 Real Estate Mortgages                 Other Debts (itemize)               
 Receivable                                                                
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 Automobiles and other                                                     
 personal property                                                         
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 Cash Value Life Insurance                                                 
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 Other assets (itemize)                                                    
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                                       TOTAL LIABILITIES                   
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                                       NET WORTH                           
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 TOTAL ASSETS                          TOTAL LIAB AND NET WORTH            
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             SOURCES OF INCOME                    PERSONAL INFORMATION           
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 Salary                  $                Business or occupation             Age 
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 Bonus and Commissions   $               Ķ
Ĵ Partner or officer in any other venture
 Dividends               $                                                       
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 Real Estate Income      $                Married           Children             
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                                          Single            Dependents           
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 TOTAL                   $                                                       
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         CONTINGENT LIABILITIES                    GENERAL INFORMATION           
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 As endorser, comaker or                  Are you defendant in any suits         
 guarantor               $                or legal actions?                      
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 On Lesses or contracts  $               *Are any assets pledged?                
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 Legal claims            $                Personal Bank Accounts carried at:     
Ĵ                                        
 Provision for Federal                   Ķ
 Income taxes            $                Have you ever taken bankruptcy?        
Ĵ Explain:                               
 Other special debt      $                                                       
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  Number of Shares                                                             
       - or -                 Description          In name of      Market value
 Face Value (Bonds)                                                            
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                   SCHEDULE OF REAL ESTATE MORTGAGES RECEIVABLE                   
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      Description of property         Date of    In name of  Amount  Maturity 
             covered                Acquisition                               
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                           SCHEDULE OF REAL ESTATE OWNED                          
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  Description of property   Date    Title in   Cost    Market    Mortgages   
     and Improvements     Acquired  Name  of           Value  AmountMaturity               
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        SCHEDULE OF LIFE INSURANCE CARRIED, INCL. N.S.L.I. GROUP INSURANCE        
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 Amount     Name of Company    Beneficiary Cash Surrender Value     Loans     
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                            SCHEDULE OF ASSETS PLEDGED                            
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             Description                   Value          To Whom Pledged       
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     GIVE NAMES OF BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN OBTAINED      
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              Name                  Date         High credit          Basis    
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               THE UNDERSIGNED CERTIFIES THAT PAGES 1 - 3 HEREOF AND THE INFORMATION
               ENTERED THERIN HAS BEEN CAREFULLY READ AND IS TRUE AND CORRECT.



_________________________ 19___   __________________________________________________
      Date Signed                                               Signature
