Federal Deposit Insurance Corporation

PERSONAL FINANCIAL STATEMENT

Privacy Act Statement

The FDIC is authorized to request this information from you by 12 U.S.C § 1819, 1820, and Executive Order 9397, as amended. The
FDIC will use this information to determine the financial viability of individuals who seek to influence or resolve their personal liability
for any obligation to or claim by the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested
information, including your social security number, may delay or prohibit any compromise or similar resolution of personal liability for
any obligation to or claim by the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign law
enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as
authorized by law, and in accordance with any of the other routine uses described in the FDIC Insured Bank Liquidation Records
(FDIC 30-64-0013) System of Records available at www.fdic.gov/about/privacy. If you have questions or concerns about the
collection or use of the information, you may contact the FDIC's Chief Privacy Officer at [email protected].

Page down to access form FDIC 7600/01

FDIC 7600/01 (7-18) Page of

 Federal Deposit Insurance Corporation
PERSONAL FINANCIAL STATEMENT

INSTRUCTIONS: Complete the identifying information at the top of this page. Return form to requester.

SECTION I - PERSONAL INFORMATION

1. Name 2. Age 3. Social Security Number 4. Date of Birth

5. Street Address 6. City

7. State 8. ZIP Code 9. Home Telephone

10. Previous Street Address

11. City 12. State 13. ZIP Code

14. Business or Occupation 15. Employer 16. Business Telephone

17. Number of Years in Present Position 18. Previously Employed By 19. Number of Years

20. Number of Dependents 21. Spouse's First Name 22. Spouse's Social Security Number 23. Spouse's Date of Birth

SECTION II - ASSETS, LIABILITIES, CONTINGENT LIABILITIES, AND MONTHLY INCOME AND EXPENSES as of:

24. ASSETS 25. LIABILITIES

List stock options, pensions, profit sharing, royalties, other preferred List and describe all other encumbrances (including, but not limited to
compensation rights. security interests, perfected or not) against any personality.

Cash, on hand and in banks - Schedule 1 Notes payable to banks - (including FDIC) - Schedule 1
Notes and accounts due me (collectable) - Schedule 2 Notes and accounts due others - Schedule 8
Merchandise and farm products - Schedule 7 Borrowed on life insurance - Schedule 3
Listed stocks and bonds - Schedule 5 Rent and interest due
Cash surrender value of life insurance - Schedule 3 Chattel mortgages
Real estate taxes due - Schedule 4
SUBTOTAL QUICK ASSETS Other liens on real estate
Real estate - Schedule 4 Judgments - Schedule 9
Machinery & fixtures (used in business) - Schedule 7
Unlisted stocks and bonds - Schedule 5
Livestock - Schedule 6

Automobile - Schedule 7 TOTAL LIABILITIES

Other assets - Schedule 7 NET WORTH

SUBTOTAL
TOTAL ASSETS

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 CONTINGENT LIABILITIES

As endorser or co-worker
My TOTAL INCOME for year ending 20 was On lease or contracts
Salary Legal claims
Commissions, fees, etc. Provisions for Federal Income tax
Interest and dividends received Other special debt
Spouse's income (source) MONTHLY INCOME AND EXPENSES
Real estate income (source) Net monthly income
Other income (source) TOTAL NET MONTHLY INCOME
Total monthly income of dependents (except spouse) Groceries (number of people)
Installment payments
GROSS INCOME Utilities (gas, water, electric, phone)
Deduct: taxes paid during year Transportation
Interest paid Insurance (life, health, home, car)
Contributions Medical

SUBTOTAL NET INCOME TOTAL EXPENSE

NET INCOME DIFFERENCE BETWEEN INCOME AND EXPENSES

COMMENTS

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 SCHEDULES

No. 1 Banking Relations. (List trust accounts, credit unions, individual retirement accounts, other retirement accounts, checking and savings accounts, certificates of deposits, money market funds, loan accounts, and
other accounts.)

How Endorsed
Add Remove Name And Location Cash Balance Amount Of Loan Maturity Date Of Loan
Guarantee Or Secured

+ -

No. 2. Accounts, Loans and Notes Receivable. (A list of the amounts owing to me/us.)

Description Or Nature Description Of Date Payment

Add Remove Name And Address Of Debtor Amount Owing Age Of Debt
Of Debt Security Held Expected

+ -

No. 3. Life Insurance

Name Of Name Of Insurance Face Amount Total Cash Total Loans Amount Of Is Policy Assigned?
Add Remove Name Of Beneficiary Type Of Policy
Person Insured Company Of Policy Surrender Value Against Policy Yearly Premium If So, To Whom?

+ -

No. 4. Real Estate. The Legal and equitable title to all the real estate listed in this statement is soley the name of the undersigned, except as follows:

Unpaid Taxes
Location Mortgages Due Dates and Amounts Of Mortgages Or Present
Add Remove Description Original Cost Year Amount
City/County Or Liens Payments Lien holder Market Value

+ -

No. 5. Stock and Bonds

Face No. Present Income Received If Pledged

Add Remove Description Of Security Registered In Name Of Cost
Value Bonds Stock Shares Market Value Last Year To Whom

+ -

TOTAL

No. 6. Livestock (Designate if mortgaged.)

Add Remove Number Kind Price Market Value

+ -
TOTAL
No. 7. Other Assets (Designate if mortgaged)
a. Are you a trustee, executor, or administrator? Yes No

b. Is anyone holding any money or anything of value on your behalf? Yes No

c. Is there any likelihood you will receive a devise, bequest, or other inheritance ever or in a given time? Yes No

FDIC 7600/01 (7-18) Page of

d. Do you receive, or under any circumstances, expect to receive, benefits from any established trust from a claim for compensation or damages or from a contingent or future interest or property of any
kind? If yes, indicate the name of the trust below and whether it is a revocable or irrevocable trust. Yes No

e. Indicate safe deposit boxes (institutions, addresses, account numbers, balances); art objects, jewelry (including watches and rings); rugs and collectibles; annuities and interests in partnerships,
patents, copyrights, trademarks, service marks, inventions, royalty agreements, licenses, franchises and other general intangibles below.

Add Remove Description Value

+ -

No. 8. Notes and Accounts Payable to Others. (Itemize every debt over $1,000)

Add Remove Name Of Creditor Origin Of Debt When Due Value

+ -

TOTAL DUE OTHERS

No. 9. Judgments. (Recorded and unrecorded.)

Add Remove To (Plaintiff) County Amount

+ -

TOTAL DUE OTHERS

No. 10. Current and Prior Business Relations

List sole proprietorship, partnerships, joint ventures, corporation or other business enterprises of any kind in which you are now or have been either a principal stock holder, officer or director, manager or
chief operating officer at any time during the past three (3) years and the value of stock or interest beneficial or otherwise which you have had in such enterprises. If the value is "0," so state.

Add Remove Description Value

+ -

TOTAL DUE OTHERS

No. 11 Financial Statements and Instruments. (Include any cashier's checks, certified checks, money orders, uncashed checks, or notes.)

Add Remove From To

+ -

a. Have you had any cashier's checks, certified checks, money orders, or uncashed checks delivered to you or to another for your benefit? Yes No

b. Have you had any financial statements prepared for you or by yourself, or have you issued any financial statements to any banks, financial institutions, corporations, firms, individuals, or other entities
within the last four (4) years? If "Yes," attach true copies. Yes No

NOTE: Attach only true and correct copies of federal income tax returns and schedules for the last three years.

Attach Files

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 SCHEDULES

OTHER LIABILITIES AND REMARKS

Transfers of all assets (real and/or personal each over $10,000.00) made by me other than in the ordinary course of business during the last three (3)
calendar years. (Include party transferred to and relationship, business or family, if any.)

Party to Whom Transferred Relationship Family Business

a. Compensation paid by recipient: Name of recipient, if applicable:

b. Total dollar amount of notes endorsed by me:

c. Transfers of real estate within last 3 years (include party transferred to, date and amount.)

Party To Whom Transferred Date Amount

d. Have you ever filed bankruptcy? If "Yes," is selected, explain below: Yes No

e. Suits pending against me/us (Civil/Criminal). Explain below.

f. Are you a partner in any venture? Yes No

There is no judgment against me/us, or lien unsatisfied upon my/our property, or suit pending against me/us in any court except as shown herein. I/we
certify that the figures and statements contained herein and all representations herein are true and complete and give a correct showing of my/our
financial condition as of the date provided in Section II. The Federal Deposit Insurance Corporation is authorized to obtain such information as may be
needed for verification. This statement is the property of the Federal Deposit Insurance Corporation. Whoever, for the purpose of influencing in any
way the action of the Federal Deposit Insurance Corporation knowingly makes or invites reliance on a false, forged, or counterfeit statement, document,
or thing shall be fined not more than $1,000,000 or imprisoned not more than 5 years or both. 18 U.S.C. § 1007.

Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up
by any trick, scheme, or device a material fact, or makes any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or
imprisoned not more than 5 years or both. 18 U.S.C. § 1001.

Note that transactions which are not disclosed on this statement may invoke applicable subsections of both 18 U.S.C. § 981 pertaining to civil forfeiture
and 18 U.S.C. § 982 pertaining to criminal forfeiture.

Date Signature

Date Signature of Spouse

Sworn to before:
Notary Public, in and for County, State of Signature of Notary Public

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