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PERSONAL FINANCIAL STATEMENT Borrower name: David Dewers Address: 251 Bates Rd. Co-borrower name: Natasha Dewers Address: 251 Bates Rd. UUUUUU uuuuu uu I (we) make the following statement of all my (our) assets and liabilities as of the 6th day of January, 20Y1 and give other material information for the purpose of obtaining credit with you on notes and bills bearing my (our) signature, endorsement, or guarantee. I (we) hereby certify that this statement presents a true, complete, and correct statement of my (our) financial condition as of the date shown and does not omit any pertinent information. I (we) understand that alimony, child support, and separate maintenance need not be revealed, unless I (we) wish to have it considered as a basis for repaying the requested credit. i (we) understand that misrepresenting information on this (or the attached) statement is a criminal offense under federal law. Instructions: Complete all schedules on pages 2 and 3, then enter any additional information on this page. Complete all blanks; enter 0, no, or none if appropriate. ASSETS LIABILITIES & NET WORTH Short-term and demand notes payable to banks and Cash on hand and in banks (Sch. 1) $ 34,000 others (Sch. 10) $ 30,000 Government securities (guaranteed) Margin debt (Sch. 11) $ Listed securities (Sch. 2) $ 39,725 Unpaid taxes and interest due this year Unlisted securities (Sch. 3) $ Other current liabilities (list below) Accounts and notes receivable (Sch. 4) $ 85,000 TOTAL LIQUID ASSETS $ 158,725 Residential real estate (Sch. 5) $ 694,000 Residential real estate mortgages (Sch. 5) $ 478,883 Non-residential real estate (Sch. 6) $ Non-residential real estate mortgages (Sch. 6) Cash value of life insurance $ 2,700 Auto loans (Sch. 7) $ Automobiles (Sch. 7) $ 35,000 Other loans and obligations (Sch. 12) $ Household furnishings & personal property $ 120,000 Credit cards (Sch. 13) 12,053 Other assets (Sch. 8 & 9) $ Other (list): Retirement accounts (401(k), Keogh, IRA, etc.) TOTAL LIABILITIES 520,936 TOTAL ASSETS $ 1,010,425 NET WORTH 489,489 ANNUAL INCOME ANNUAL EXPENSES Salary $ 218,000 Mortgage payments, residential RE (Sch. 5) $ 32,952 Interest Mortgage payments, non-residential RE (Sch. 6) $ Dividends Other loan & credit card payments (Sch. 7, 10, 12, 13) $ 30,000 Residential real estate income (Sch. 5) $ Required partnership contributions Non-residential real estate income (Sch. 6) $ Taxes: Income, real estate, etc. $ 5,332 Other business income (Sch. 3 and 8) $ Insurance premiums $ 1,250 Other recurring income (Sch. 9) $ Living expenses, etc. $ 12,000 Non-recurring or variable income Alimony, child support, separate maintenance Commissions and bonuses Charitable contributions Other: Other contractual obligations (tuition, etc.) Other: Other (attach list) TOTAL 218,000 TOTAL $ 81,534 PERSONAL INFORMATION GENERAL INFORMATION Enter Yes or No Business or occupation: Are any assets pledged? List. Accountant, teacher Real estate, money market account Yes Partner or officer in other venture(s) (List): Are you defendant in any suits or legal action? No no Have you ever made a composition settlement? No Name(s) and age(s) of dependents Have you taken bankruptcy? If yes, when? No Are any assets held in trust? No CONTINGENT LIABILITIES Enter Yes or No Circumstances and potential liability As endorser, co-maker, or guarantor? No Pending legal claims against you? No none Borrower's signature David Dewery Co-borrower's signature Natasha Demers 1/6/41 Date 1/6/41 Date PERSONAL FINANCIAL STATEMENT, continued David Dewers SUPPLEMENTARY SCHEDULES 1-6 (Attach separate sheets if necessary) Sch. 1, Assets: List cash on hand if significant, and all bank accounts Ownership Financial institution Type of account Balance (Individual, Joint) Mid-America Bank Checking $9,000 J Mid-America Bank Money market $25,000 Interest income last year Amount pledged To whom pledged $25,000 Mid-America Bank Sch. 2: Assets: Listed securities (other than guaranteed government securities) Face value (bonds) Description of security or Ownership Income received or # of shares managed by (Individual, Joint) last year 250 shares ATT 200 shares Microsoft 225 shares McDonalds J Various Various tech stocks held at Scottrade Sch. 3, Assets: Unlisted securities, ownership interest in private corporations Face value (bonds) Percent of or # of shares Description of security ownership Current value Present market value $4,412 $15,750 $6,507 $13,056 If pledged, amount pledged and to n/a n/a n/a n/a Non-salary income rec'd last year Basis for valuation Sch. 4, Assets: Notes receivable Name of debtor and relationship to applicant Susan & Michael Walters (daughter) Amount owing Description of collateral eld When is payment expected? Age of debt Description of nature of debt down pmt on home, $100,000 $85,000 1.5 years none monthly Annualized payments Annual income, net of expenses, before debt service Sch. 5, Assets and liabilities: Residential real estate and mortgages payable Description of property and Current market Balance of related ownership % value debt Lienholder Years to maturity Residence, 251 Bates $369,000 $183,883 Mid-America Bank 18 Vacation home, Palm Desert, CA $325,000 $295,000 Mid-America Bank 25 $8,244 $24,708 Sch. 6, Assets and liabilities: Non-residential real estate and mortgages payable Description of property and Current market Balance of related ownership % Lienholder Years to maturity Annual income, net of expenses, before debt service value Annualized payments debt PERSONAL FINANCIAL STATEMENT, continued David Dewers SUPPLEMENTARY SCHEDULES 7-13 (Attach separate sheets if necessary) Sch. 7, Liabilities: Autos and auto loans vehicle (year, Current market Balance of related model, make) Original cost value debt Audi $35,000 $25,000 Mini Cooper $20,000 $10,000 Annualized payments Lienholder Years to maturity Sch. 8, Assets and Income: Other business income (partnership distributions, capital withdrawals, etc.; exclude corporations) Business name and ownership Amount received Future annual percentage Value of your share last year income Type of income Shown in tax return? Form or Schedule: Sch. 9, Assets and Income: Other significant assets and recurring income (trust income, annuities, pensions, etc.) Other asset or Current market Income received Future annual source of income value last year income Type of income Shown in tax return? Form or Schedule: Sch. 10, Liabilities: Short-term notes payable to banks and others Name of lender Outstanding Maturity date Collateral Mid-America Bank $30,000 June 1, 20Y1 Money market acct Investments Purpose, comments Sch. 11, Liabilities: Margin debt Name of lender Original amount Present balance Rate Payment terms Maturity Collateral Sch. 12, Liabilities: Other loans and obligations Name of lender Original amount Present balance Annualized payments Rate Maturity Collateral Sch. 13, Liabilities: Credit cards Annualized payments Rate Name of lender Nova Mastercard Notes Credit limit $15,000 Paid in full monthly? No Present balance $12,053