Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327
Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949

Personal Financial Statement -- CONFIDENTIAL

Name:

Position or Occupation:

Employer Name & Address:

Home Address:

Home Phone#: ( )

Work Phone#: ( )

Spouse Name:

SSN:

Spouse SSN:

Date:

This Personal Financial Statement is submitted for the purpose of procuring, establishing and maintaining credit with Lease$mart on behalf of the undersigned, or persons, firms or corporations in whose behalf the undersigned may either severally or jointly with others execute a guaranty in favor of Lease$mart. The undersigned warrants that this Personal Financial Statement is true and correct and that Lease$mart may consider this Personal Financial Statement as continuing to be true and correct until a written notice of a change is given to Lease$mart by the undersigned.

ASSETS	In Even Dollars	LIABILITIES	In Even Dollars
Cash on hand and in banks:	$	Notes payable to banks (secured):	$
Marketable securities (Schedule A):	$	Notes payable to banks (unsecured):	$
Non-marketable securities (Schedule B):	$	Due to Brokers:	$
Securities with Broker in margin account:	$	Amounts payable to others (secured):	$
Restricted or control stocks:	$	Amounts payable to others (unsecured):	$
Partial interests in Real Estate (Schedule C):	$	Accounts and bills due:	$
Real Estate owned (Schedule D):	$	Real Estate Mortgages (Schedule D):	$
Loans receivable:	$	Other unpaid taxes & interest:	$
Autos & other property:	$	Unpaid income taxes:	$
Businesses owned - market value (Schedule B):	$	Owed against business / business assets:	$
Cash value of life insurance (Schedule E):	$	Other debts (itemize):	$
	$		$
	$		$
	$		$
	$	Total Liabilities:	$
	$	Net Worth:	$
Total Assets:	$	Total Liabilities + Net Worth:	$

Are all bad and doubtful assets excluded from this statement? Yes___ No___ If No, explain:________________________________________

Income taxes settled through what date? ____________________ Additional assessments due: $____________________

ANNUAL SOURCES OF INCOME		PERSONAL INFORMATION
Salary, bonus & commissions:	$	Do you have a will? Yes___ No___ If Yes, name of executor:
Dividends:	$	Do you have a will? Yes___ No___ If Yes, name of executor:
Real Estate income:	$	Are you a partner in any other venture? Yes___ No___ If Yes, explain:
Retirement & pensions:	$
Other Income: (alimony, child support or separate maintenance need not be revealed if you do no wish to have it considered as a basis for repaying obligations.)	$	GENERAL INFORMATION
	$	Are you a defendant in any suits or legal actions? Yes___ No___ If Yes, explain:
CONTINGENT LIABILITIES	Do you have any contingent liabilities? Give details.
As endorser, co-maker or guarantor:	$	Are any assets pledged? Yes___ No___ If Yes, explain:
Legal claims:	$	Are any assets pledged? Yes___ No___ If Yes, explain:
Other special debt:	$	Have you ever taken bankruptcy? Yes___ No___ If Yes, explain:
Amount of contested income tax liens:	$

(COMPLETE SCHEDULES and SIGN ON PAGE 2)

www.lease-smart.com

pg break

Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327
Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949

Page 2 -- Personal Financial Statement -- CONFIDENTIAL

SCHEDULE A -- U.S. GOVERNMENTS AND MARKETABLE SECURITIES
No. of Shares or Face Value of Bonds	Description	In Name of:	Current Market Value
			$
			$
			$
			$

SCHEDULE B -- NON-MARKETABLE SECURITIES AND BUSINESS INTERESTS

Description of Securities

No. of Shares

Book Value as per Financial Statement

Dated: MM / YY

$ Book Value Equity

No. of Shares Outstanding

Total Value

Dated: /

SCHEDULE C -- PARTIAL INTERESTS IN REAL ESTATE EQUITIES, PARTNERSHIPS, ETC.

Location of Property

% of
Ownership

Type

Year of
Purchase

$Cost (C) or
$Market Value (M)

Mortgage
Balance

Value
of Equity

( )

SCHEDULE D -- REAL ESTATE OWNED
Description of Property and Improvements	Date Acquired	Title in Name of:	Cost	Market Value	Mortgage Amount	Mortgage Maturity Date
			$	$	$
			$	$	$
			$	$	$

SCHEDULE E -- LIFE INSURANCE CARRIED, INCL. N.S.L.I. AND GROUP INSURANCE
Face Amount	Name of Insurance Company	Name of Beneficiary	Cash Surrender Value	Loans
$			$	$
$			$	$
$			$	$

SCHEDULE F -- NAMES OF BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN
Name of Bank or Finance Company	Date	High Credit	Owe Currently	Secured or Unsecured
		$	$	Secured / Unsecured
		$	$	Secured / Unsecured
		$	$	Secured / Unsecured
		$	$	Secured / Unsecured
		$	$	Secured / Unsecured

(USE ADDITIONAL SCHEDULES WHEN NECESSARY)

The undersigned certifies that both pages hereof and the information inserted therein has been carefully read and is true, correct and complete, and may be verified where Lease$mart deems necessary.

X________________________________________ signature required		Date Signed:______________________________
X________________________________________ signature required		Date Signed:______________________________

Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327 Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949 Personal Financial Statement -- CONFIDENTIAL

Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327 Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949

Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327
Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949

Personal Financial Statement -- CONFIDENTIAL

Lease $mart, 11384 SW 78th Circle, Ocala, FL 34476-9327
Phone: 520-628-9929 or 800-532-7303 (800-LEASE-03) Fax: 520-628-9949