CLEAR LAKE BANK & TRUST CO.

AGRICULTURAL FINANCIAL STATEMENT

BORROWER:________________________________SS#____________________ BIRTHDATE_______________
ADDRESS:____________________________________________________________________________________

BORROWER

___ (is)___ (is not) jointly engaged as a principal in the farming operation described in this statement.

Name(s) of other principal(s) and their relationship to the Borrower, if any, are:_____________________________________________
Borrower agrees to promptly notify lender in writing of any change in the principals engaged in the farm opeation.
NO. DEPENDENTS_________ AGES ____________ BIRTHDATE ________________ OFF FARM EMPLOYMENT___________________
DATE_________________ TO: (Bank) Clear Lake Bank and Trust Company

PHONE__________________________

ASSETS
CURRENT ASSETS
Cash-Checking Acct.
Savings & C.D.'s
Accts.-Notes Rec.
Cash Value Life Ins. (Schedule D)
Livestock Held for Sale (Schedule A)
Grain & Feed on hand (Schedule B)

LIABILITIES
CURRENT LIABILITIES

Sealed Grain
P.D. Fert.

Payable to Relatives
Payable to Others

Herb., Insecticides, etc.

Mortgages Payable (Due this year)

Cash Rent Payable

Elevator
Chem Co.
Mach. Dealer
Gas
ASCS

Trading Accts.
Stocks, Bonds (Schedule E)

RE Taxes Payable
Income Taxes Payable
Part Inter. Debt. Due

Other

Other

TOTAL CURRRENT ASSETS

INTERMEDIATE TERM ASSETS
Autos, Trucks, (Schedule F)
Machinery & Tools (Schedule F)

TOTAL CURRENT LIABILITIES

INTERMEDIATE TERM LIABILITIES
Tractor
Combine
Auto
Truck

TOTAL INTERMEDIATE LIABILITIES

LONG TERM LIABILITIES
Real Estate Mortgages * Except
that portion listed under Current Assts

TOTAL --- Long Term Liabilities

TOTAL LIABILITIES

$
$

Breeding Stock

Other
TOTAL INTERMEDIATE ASSETS
LONG TERM OR FIXED ASSETS
Farm Real Estate (Schedule C)

Other Real Estate (Schedule C)

Pension &/or Annuities (Vested Int.)

TOTAL---FIXED ASSETS
TOTAL ASSETS

$
$

Workers Compensation

Yes

No

PRESENT NET WORTH

TOTAL LIABILITIES & NET WORTH
Have you been declared bankrupt in the last 10 years?

YES

NO
NO

Insurance on Crops

Are any Suites pending against you?

YES

Insurance on Buildings (Fire, Ext.Cov)

Do you carry health, accident or hospital insurance?

YES NO

Insurance on Machinery, Equip, Livest)

Liability Insurance Coverage?

List Continqent Liabilities

Estate Plan?

$
YES NO

Number

SCHEDULE A - Livestock Held for Sale

Description
Wt.
Price

Total

TOTAL HELD FOR SALE

Total Held for Breeding Stock

SCHEDULE B - Crops or Feed on Hand or Growing

Amt
Type & Location
Pr/UL
Value

TOTAL
Acres Crops Growing on Or To Be Grown
Crop
Acres
Pr/Ut.
Value

TOTAL BREEDING STOCK

SCHEDULE C - Real Estate - Owned or Rented
FARM REAL ESTATE - OWNED
Acres
Description/Location Title as:

TOTAL

Cost

Value

Encumbrances

Due Date

Rate

Mortgagee

NON-FARM REAL ESTATE - OWNED

Description and Location
Title as:

Cost

Value

Encumbrances

Due Date

Rate

Mortgagee

FARM REAL ESTATE - RENTED

Acres
From Whom

SCHEDULE D - Life insurance

Insurance Company Benefic.

Face Value

SCHEDULE F - Machinery and Equipment

Year
Kind
Cost

Location/Description

Terms and Tilliable Acres

SCHEDULE E - Bonds and Securities (in your name)

Cash Value # of Shares of Par Value
Description

Mkt Value

Value

Value

Year

Kind

TOTAL

Cost

The information contained in this statement is provided for the purpose of obtaining, or maintaining credit with you on behalf of the undersigned, or persons,
firms or corporations in whose behalf the undersigned may either severally or jointly with others execute a guaranty in your favor. Each undersigned
understands that you are relying on the information provided herein (including the designation made as to ownership of property) in deciding to grant or
continue credit. Eash undersigned represents and warratns that the information provided is true and complete and that you may consider this statement
as continuing to be true and correct until written notice of a change is given to you by the undersigned. You are Authorized to make all inquiries you deem
necessary to verify the accuracy of the statements made herein, and determine my/our creditworthiness. You are authorized to answer questions about your
credit experience with me/us.

DATE:
Bank Officer:______________________________

Signature:
Signature: