Appendix C YEARLY CASH-FLOW STATEMENT. Loan or Note Payments. Auto Lease/Loan Payments. Utilities, etc.,) Credit Card Payments. Pension (IRA, Keogh)

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1 Appendix C YEARLY CASH-FLOW STATEMENT If the income tax return you submit with this application is for the prior calendar year, then complete this form for the current calendar year only. If you have not submitted a filed income tax return for the prior calendar year, please complete two forms: one for the preceding year and one for the current calendar year. Applicant s Name: Income Salary (or earned income) Expenses Mortgage (Principal & ) Bonus and Commissions Real Estate Income (Net) Share of Partnership Income (Loss) Business Income (Net) Sole Proprietorship Dividends Pension (IRA, Keogh) Social Security Investments (describe) Capital Gains (Describe) Other Income (Itemize) TOTAL INCOME Real Estate Taxes Rent/Co-op Condo Maintenance Loan or Note s Auto Lease/Loan s Insurance s Tuition Expenses Charitable Contributions Medical (Non-reimbursed) Alimony, Child Support/Maintenance Living Expenses (food, Clothing, Utilities, etc.,) Credit Card s Pension (IRA, Keogh) Taxes Partnership Contributions Other Expenses (Itemize) TOTAL EXPENSES List any unsatisfied judgments or legal actions pending against you and the amounts involved: Have you ever gone through bankruptcy or other insolvency proceedings? I/we represent and warrant that the above information is true and complete and that 50 West 67 th Street, Inc. may rely on it as a basis for making its decision on the merits of the application included herewith. :

2 Applicant s Name: Appendix D STATEMENT OF FINANCIAL CONDITION Statement of Financial Condition as of the day of, 20 Please note: Supporting documentation for all aspects and liabilities must be attached to this statement. Use the word none where no amount if to be entered. Assets Cash (Complete Schedule A attach 3 months bank statements) Downpayment on Contract (if applicable) Marketable Securities (Schedule H attach Statements) Cash Surrender Value of Life Insurance (Schedule G) Real Estate Owned Market Value (Schedule I) Private Owned Business Market Value (Schedule J) Vested in Retirement Fund 401K, IRA, Keogh (Schedule L Attach Statement) Automobile Make and Year Mortgages and Loans Receivable (Schedule M) Limited Partnership s (Cost) (Schedule K) Personal Property Liabilities Loans payable to Bank Unsecured (Schedule B) Loans Payable to Bank Secured ( Secured (Schedule B) Loans Payable to Others (Schedule D) Margin Loans Mortgages payable (Schedule C) Loans against Life Insurance Federal & State Income Taxes Payable Other Taxes & Payable Installment Contracts Payable (Schedule F) Accounts Payable (Schedule E) Outstanding Credit Card s (Schedule F) Other Assets (Schedule N Itemize) Other Liabilities (Schedule O Itemize) TOTAL ASSETS TOTAL LIABILITIES NET WORTH

3 SCHEDULE A CASH BALANCES Name & Location of Bank or Financial Institution Type of Account & Account Number Signatures on Account Check (x) if pledged Cash s BALANCES $ TOTAL CASH SCHEDULE B LOANS PAYABLE TO BANKS Lender Original Collateral Description Maturity Monthly PAYABLE $ TOTAL LOANS SCHEDULE C MORTGAGE PAYABLE Lender Title Original Type of Lien (1 st, 2 nd, etc.,) Maturity Monthly PAYABLE $ TOTAL LOANS

4 SCHEDULE D LOANS PAYABLE TO OTHERS Lender Nature of Loan Original Collateral Maturity Monthly OTHERS $ TOTAL LOANS PAYABLE TO SCHEDULE E ACCOUNTS PAYABLE (include credit card balance) Creditor In Name of Maturity Monthly SCHEDULE F INSTALLMENT CONTRACTS, LEASES Creditor Underlying Asset In Name of Maturity Monthly SCHEDULE G CASH SURRENDER VALUE OF LIFE INSURANCE CONTRACTS Insurer s Name Policy Type & No. Face amount of Policy Beneficiary CSV Value $ TOTAL CASH SURRENDER

5 SCHEDULE H MARKETABLE SECURITIES Security No. of Shares/Principal Price Acquired Cost Basis Market Value SECURITIES $ TOTAL MARKET VALUE OF

6 SCHEDULE I REAL ESTATE OWNED Location & Type of Property Title % Owned Acquired Cost Recent Appraisal Mortgage Mat Monthly TOTAL VALUE OF OWNED REAL ESTATE $ SCHEDULE J PRIVATELY OWNED BUSINESSES Name/Type of Business Acquired % Owned Gross Revenue 3 Years Net Profit 3 Years Cost Market Value METHOD OF DETERMINING MARKET VALUE: TOTAL VALUE $ SCHEDULE K LIMITED PARTNERSHIP INTERESTS Title & Description (Real Estate, Oil, & Gas, Financial) % Owned Cost Cash Distribution This Year Last Year Net Equity SCHEDULE L VESTED INTERESTS IN RETIREMENT FUNDS (401k, IRA, KEOGH) Fund Type Beneficiary Market Value TOTAL VALUE OF VESTED RETIREMENT FUNDS $

7 SCHEDULE M MORTGAGE OWNED & LOANS RECEIVABLE Debtor Original Maturity Collateral Monthly Principal BALANCE $ TOTAL RECEIVABLE SCHEDULE N OTHER ASSETS (ITEMIZE) Debtor Original Maturity Collateral Monthly Principal TOTAL $ SCHEDULE O OTHER LIABILITIES (ITEMIZE) Debtor Original Maturity Collateral Monthly Principal TOTAL The foregoing statements and details pertaining thereto, both printed and written, have been carefully read and the undersigned represents and warrants that same is a full correct exhibit of my/our financial condition. :