INDIVIDUAL FINANCIAL STATEMENT

legally separatedunmarried married : ma IFor Wisconsin residents only

AddressName of spouse

IMPORTANT: Date and sign statement

(For Wisconsin residents only)

For the purpose of obtaining credit from Lender and any future credit granted by Lender, or to support the extension of credit already given, I make the

. This statement is Lender's property.following statement to Lender of my financial condition on

Name

COMPLETE ALL BLANKS, WRITING "NO" OR "NONE" WHERE NECESSARY

TOTAL LIABILITIES and NET WORTHTOTAL ASSETS

*For Married Wisconsin residents, name each spouse and include the income of each spouse.

**Income from Alimony, Child Support or Separate Maintenance income and income from medical insurance, disability or wage continuation insurance need not

be revealed

if you do not wish the Lender to consider this income on determining your creditworthiness.

Total Liabilities

Assets less Liabilities = Net Worth

COMPLETE SCHEDU LES ON THE FOLLOWING PAGES AND SIGN ON PAGE 5

Marital property means assets acquired with my or my spouse's income on or after 1-1-86; and

Individual property means property owned (whether in joint or sole name) by me prior to marriage, prior to establishing residence in Wisconsin, or prior to

1-1-86, however acquired, and property acquired by me by gift or inheritance at any time.

NOTICE TO MARRIED APPLICANTS: No provision of any marital property agreement, unilateral statement under § 766.59, Wis. Stats., or court decree under

§ 766.70, Wis. Stats., adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted or an open-end credit plan is entered

into, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision.

INSTRUCTIONS FOR INFORMATION TO BE SUPPLIED BELOW:

Individual Credit. If a married applicant is applying for individual credit, complete this statement including all marital property and all individual

property of the applicant, but do not include individual property of the non-applicant spouse. Include all liabilities of both spouses. Only the

applicant must sign on page 5.

Joint Credit with spouse as joint applicant. If married applicants are applying for joint credit, include all assets and all liabilities of both spouses.

Both spouses must sign this statement.

Joint Credit with as joint applicant who is not your spouse. If a married applicant is applying for

joint credit with someone other than his or her spouse, each applicant must complete a separate statement as if applying for individual credit,

including all marital property and all individual property of the applicant. Do not include any individual property of the non-applicant spouse. Include

all liabilities of the applicant and the applicant’s spouse. Only the applicant must sign on page 5.

For purposes of this statement:

Cash on Hand and in Financial Institutions (Schedule A)

Gov't Securities (Schedule B-1)

Unlisted Securities (Schedule B-3)

Notes and Loans Receivable (Schedule F)

Homestead and Real Estate Owned (Schedule D)

Automobiles

Other Personal Property

Cash Value Life Insurance (Schedule C)

Securities Held by Brokers in Margin Accts.

Equity in Partnership

Equity in Proprietorship

Vested Pension Benefits or Profit Sharing

Other Assets: (Itemize Below)

*Salaries & Bonuses

Commissions

InterestDividends &

EstateReal

rehtO **

As Endorser, Co-Maker, or Guarantor

On Lease or Contracts

Legal Claims

Other (describe)

127 (2/20/20)

11031W. B. A.

Date of Financial Statement

(Schedule E-1) Notes Payable - Lenders/Secured

Notes Payable - Lenders/Unsecured (Schedule E-2)

Notes Payable Others (Schedule E-3)

Life Insurance Loans (Schedule C)

Due to Brokers

Accounts Payable

Unpaid Income Taxes

Real Estate Mortgage Payable (Schedule D)

Real Estate Taxes

Credit Cards

Other Debts (Itemize Below)

Page 1 of 5

ePDF

Address

")Lender("

Publicly Traded Securities (Schedule B-2)

ASSETS

LIABILITIES OF APPLICANT AND SPOUSE

SOURCES OF INCOME FOR YEAR ENDED

CONTINGENT LIABILITIES OF APPLICANT AND SPOUSE

SOURCES OF INCOME FOR YEAR ENDED

CONTINGENT LIABILITIES OF APPLICANT AND SPOUSE

$ 0.00

DepositSchedule A - Cash, Checking Accounts, Savings Accounts, & Certificates of

Type

Name of Financial Institution

Amount

In Name Of:

PLEDGED

Schedule B-1 - U.S. Government Securities

FaceNo. of Shares or

Value (Of Bonds)

Description*

Owner

ValueMarket

*Indicates if Securities are Restricted By Contract or SEC Regulations.

NO YES

PLEDGED

NOYES

Schedule B-2 - Publicly Traded Securities

FaceNo. of Shares or

Value (Of Bonds)

Description*

Owner

ValueMarket

*Indicates if Securities are Restricted By Contract or SEC Regulations.

PLEDGED

NOYES

Schedule B-3 - Unlisted Securities

FaceNo. of Shares or

Value (Of Bonds)

Description*

Owner

ValueMarket

PLEDGED

NOYES

INDIVIDUAL FINANCIAL STATEMENT

Page 2 of 5

PERSONAL INFORMATION

Date of BirthSocial Security No. Home Telephone

Employer(s) of Applicant(s)

Are any assets pledged or restricted other than indicated on the following schedules? If so, describe.

Are you a defendant in any legal actions or suits? If so, describe.

Are you a partner or officer in any other venture? If so, describe.

No If so, name of Personal RepresentativeYes Do you have a will?

Have you ever been declared Bankrupt? If so, describe.

State ID Card) Name, No., State and Expiration DateDriver's License (or

Yes, and give Prior NameNo Changed Name on Driver's License or State ID Card in Past 5 Years

*Indicates if Securities are Restricted By Contract or SEC Regulations.

Schedule C - Life Insurance Carried, Include Group

Face Amount

Name of Company

Owner

Beneficiary

Loans

CASH SURRENDER

Value

Schedule E-1 - Notes Payable - Lenders/Secured

Name & Address of Lender

Date Made

Due

High Credit

Current

Balance

Borrower

Monthly

Payment

Schedule D - Real Estate Owned

Address & Type of Property

Owner

Mkt. Value

Insurance

Date

Acquired

Amount

Monthly $

Maturity

MORTGAGE

Cost

INDIVIDUAL FINANCIAL STATEMENT

Page 3 of 5

Schedule E-2 - Notes Payable - Lenders/Unsecured

Name & Address of Lender

Date Made

Due

High Credit

Current

Balance

Borrower

Monthly

Payment

Schedule F - Notes and Loans Receivable

Unpaid Amount

Name of Maker

Date Made

Security Pledged

Schedule E-3 - Notes Payable - Others

Name & Address of Lender

Date Made

Due

High Credit

Current

Balance

Borrower

Monthly

Payment

INDIVIDUAL FINANCIAL STATEMENT

Page 4 of 5

INDIVIDUAL FINANCIAL STATEMENT

Page 5 of 5

NOTICE: We may report information about your account to credit bureaus. Late payments, missed payments, or other defaults on your account may be

reflected in your credit report.

I certify that this financial statement is true and complete. I authorize Lender or its agents to verify the information obtain ed in this statement and to obtain

additional information concerning my financial condition, including, without limitation, consumer credit reports, although Lender may rely on this financial

statement without any further verification. I authorize Lender to furnish such information and any other credit experiences with me to others and to answer any

questions about my credit experience and other financial relationships with Lender, to the extent not prohibited by applicable law. I agree to notify Lender, in

writing, of any change that materially affects the accuracy of this statement.

It may be a crime punishable by a fine or imprisonment or both to knowingly make false statements concerning any of the above information, under provisions

of applicable federal and state law.

For married Wisconsin resident. I understand Lender may be required by law

give notice of any credit transaction to my spouse. The credit applied for, if

granted, will be incurred in the interest of my marriage or family.

Joint Applicant Spouse Signature (joint credit only)

Applicant Signature

(Date Signed)

Applicant Signature