APPLICATION - FINANCIAL STATEMENT

Name of Applicant:
Bank:
Address:
City, State, Zip:
Phone:

 
LAWYER, BANKER, OR OTHER BUSINESS/FINANCIAL ADVISOR
Name:
Address:
City, State, Zip:
Phone:
Name:
Address:
City, State, Zip:
Phone:
Finances Administered: By Self By Another
Name (if another):
Address:
City, State, Zip:
Phone:

FINANCIAL STATEMENT DATE:
 
ASSETS
CASH
NOTES RECEIVABLE
LISTED STOCKS
UNLISTED STOCKS AND BONDS
CITY REAL ESTATE
COUNTRY REAL ESTATE
OIL AND GAS PROPERTIES
PERSONAL PROPERTY
CERTIFICATES OF DEPOSIT
TRUSTS
OTHER ASSETS
TOTAL ASSETS
CONDENSED STATEMENT OF INCOME

INCOME FROM STOCKS AND BONDS
INCOME FROM REAL ESTATE
INCOME FROM OIL AND GAS
INCOME FROM SOCIAL SECURITY
INCOME FROM OTHER PENSIONS (i.e. V.A., RR)
INCOME FROM TRUSTS
INCOME FROM CERTIFICATES OF DEPOSIT
OTHER INCOME
TOTAL INCOME

 
LIABILITIES
NOTES PAYABLE: MONTHLY
BANK:
OTHER:
ACCOUNTS PAYABLE
MORTGAGE PAYABLE
OTHER LIABILITIES
TOTAL LIABILITIES

I HEREBY SOLEMLY CERTIFY AND DECLARE THAT THE ABOVE STATEMENT AND REPRESENTATION CONSTITUE A TRUE AND ACCURATE ACCOUNT OF MY FINANCIAL CONDITION AS OF THE DATE FIRST ABOVE WRITTEN.

PRINT THESE PAGES and deliver via mail or fax to:
Saint Simeon's Episcopal Home
3701 North Cincinnati
Tulsa, Oklahoma 74106
Phone: 918.425.3583
Fax: 918.425.6368