AGRICULTURAL FINANCIAL STATEMENT
BORROWER(S):
SS# OR TAX ID #
DATE OF BIRTH
CO-BORROWER OR D.B.A.
SS# OR TAX ID #
DATE OF BIRTH
___Individual
___Partnership
___
ADDRESS
STREET OR RURAL ROUTE
TOWN
COUNTY
STATE
p
ZIP CODE
DIRECTIONS TO RESIDENCE
TO:
BANK
ADDRESS
DATE OF STATEMENT
Green Belt Bank & Trust
For the purpose of obtaining loans with this bank, I/We furnish the following statement of my/our financial condition on the
above given date and is certified to be true and correct. I/We will notify the bank promptly of any material change.
CURRENT ASSETS
1.
2.
3.
4.
5.
6.
7.
Cash in Hand and in Bank
Savings & Certificate(Sch A)
Crops and Feed on Hand(Sch B)
Livestock Held for Sale(Sch C)
Marketable Bonds & Stock(Sch D)
Accounts Receivable
Note and Contracts Receivable
8. Cash Invested in Crop(Sch E)
9. CCC or Government Payments
10. Other Current Assets
CURRENT LIABILITIES
$0
$0
$0
$0
$0
$0
$0
$0
$0
31.
32.
33.
34.
35.
36.
37.
Cash Value of LIfe Insurance
Machinery & Equipment(Sch F)
Breeding Stock(Sch G)
Securities Not Readily Marketable
Household Goods
Other Intermediate Assets
$0
$0
$0
$0
Current Due on Intermed. Debt
Accounts Payable (Gas, Feed)
Current Maturity Term Debt
Cash Rent Due and Taxes
Other Current Liabilities
Due Relatives
Interest Due
$0
$0
38. TOTAL CURRENT LIABILITIES
39. CA:CL RATIO
INTERMEDIATE ASSETS
13.
14.
15.
16.
17.
18.
Due within 12 Mos.
CCC corn loan
$0
$0
11. TOTAL CURRENT ASSETS
12. NET CURRENT POSITIONS(W. Cap.)
30.
To Whom and Collateral
Notes Due This Bank & Others
Income tax-Fed & State
CCC soy loan
$0
:1
INTERMEDIATE LIABILITIES
$0
$0
$0
$0
40.
41.
42.
43.
44.
45.
To Whom and Collateral
CVL Insurance Loans
Machinery Loans
Breeding Stock Loans
Household Goods Loans
Due beyond 12 Mos.
$0
19. TOTAL INTERMEDIATE ASSETS
20. NET INTERMEDIATE POSITION
$0
$0
46. TOTAL INTERMEDIATE LIABILITIES
47. IA : IL RATIO
LONG TERM OR FIXED ASSETS (Sch. I)
21.
22.
23.
24.
25.
Farm Real Estate
City Real Estate
Other Real Estate
Grain Holding & Storage
Mortgages or Contracts Held
26.
27.
28.
29.
TOTAL FIXED ASSETS
NET FIXED POSITION
DEBT : WORTH RATIO
TOTAL ASSETS
$0
:1
LONG TERM LIABILITIES (Sch I)
Not Incl'd. Above
48. Balance Due on Mortgages & Contracts
49.
50.
51.
:1 52.
$0
53.
$0
$0
TOTAL LONG TERM LIABILITIES
FA : LTL RATIO
TOTAL LIABILITIES
PRESENT NET WORTH
TOTAL LIABILTIES & NET WORTH
$0
:1
$0
$0
$0
I/We further certify that all information contained in the foregoing statement was completed before I/We signed hereunder.
I/We acknowledged receipt of a copy of this statement.
Date____________________________________20______ Signed
_________________________________
Witness__________________________________________Signed
_________________________________
Name
_________________________________
(Title)
Schedule A - Savings and Certificates
Schedule F - Machinery and Equipment
Description
Number
Value
Kind
No.
Make
Model
Year
Value
Autos
0
Baler
To Line 1 Sch. A Total
Combine
$0
Schedule B - Crops & Feed on Hand
Amount on Hand
Crop/Feed
Corn Picker
Price
Cultivator
Value
$0.00
0
$0.00
0
Disc
Drill
Elevator
Field Cult.
To Line 2 Sch. B Total
Forage Har.
$0
Gr. Dryer
Schedule C - Livestock Held for Sale
Number
Weight
Description
Price
Grinder
Harrow
Value
Lvstk. Eq.
Manure Spr.
Mower
To Line 3 Sch. C Total
Planter
$0
Plow
Schedule D - Marketable bonds and Stocks
Description
Number
Par Value
Rotary Hoe
Value
Sprayer
Tools
Tractors
To Line 4 Sch. D Total
Trucks
$0
Schedule E - Cash Invested in Crop -
Wagons
List Total Share of Planned or Current Acres by Crop
Crops or Material
Total
Your Share
Other(List)
Value
$0
$0
$0
$0
To Line 7 Sch. E Total
To Line 13 Sch. F Total Value
$0
Schedule G - Breeding Livestock
1.Number of Dependents:
2.Involved in Bankruptcy?
No.
3.Any Suits Pending?
4.Employee family members
$0
Description
Age
Weight
Price
Value
$0
Total Salaries
$0
Total Income
$0
5.Other Jobs or Business Interests:
6.Contingent Liabilities
7.Face Value of Life Insurance :
$0
8.Beneficiary:
To Line 14 Sch. G. Total
9.Accident & Health Limits :
10.Livestock Insurance Limits :
11.Crop Insurance & Type :
$0
Schedule H Ownership Designations
12.Bldg Fire & Ext Cov. Limits :
(*) Indicate Type of Ownership by a following number
13.Machinery Insurance Limits :
1. Ownership in Joint Tenancy as Husband and Wife with Full Rights
14.Liability Insurance Limits :
of Survivorship
15.Year Last Will Was Written - 19______
2. Other Joint Tenancy_________________________________________
16.Location of Last Will:
3. Ownership as Tenants in Common
4. Single Ownership
5. Partnership - Your _________% of interest
6. Trust of Estate - Your _________% of interest
7. Corporation - Your _________% of interest
8. Other(list)________________________________________________
$0
Schedule H - Real Estate Schedule
1. Name of Property
2. Acres
3. Legal Description
4. Type of Lease OR
5. Name(s) on Title
6. Type of Ownership(*)
7. Year Purchased
8.
9. Present Market Value
10. Mortgage or Contract
Total Balance Due
-Include Farm, City and Other Real Estate, Mortgages, Contracts and Grain Equipment