STOCKS & BONDS (TRADED), AND RETIREMENT ACCOUNTS (Schedule C)

(Schedule G)

Winfield, KS 67156 This form licensed to: The Bank of Beaver City; Beaver, OK • For website use only.

CONTINGENT LIABILITIES (Schedule B)

INCOME INFORMATION FOR D CO-APPLICANT INCOME THE YEAR ENDING---------------

Alimony, child support, or separate maintenance income need not be revealed SALARIES

if you do not wish to have it considered as a basis for repaying this debt.

OTHER (DESCRIBE)

COMMISSIONS

DIVIDENDS TOTAL ALL INCOME

ANY ADDITIONAL ASSESSMENTS? 1 IF YES, AMOUNTTAX RETURN HAS BEEN FILED THROUGH (DATE) I

DYES D NO I

AMOUNT OF INCOME TAXES PAID LAST YEAR

SCHEDULE A. NOTES DUE ME

DUE FROM ORIGINAL AMOUNT BALANCE OWING PAYMENTS MATURITY COLLATERAL

TOTAL

SCHEDULE B. CONTINGENT LIABILITIES

DUE TO BALANCE OWING PAYMENTS MATURITY COLLATERAL

ENDORSER OR

COSIGNER?

GUARANTOR

LEASES OR

CONTRACTS

LEGAL CLAIMS OR

JUDGEMENTS

OTHER (DESCRIBE)*

• ALIMONY, CHILD SUPPORT, ETC. TOTAL

SCHEDULE C. STOCKS & BONDS (traded)

NO.OF REGISTERED SOURCE OF PRICE PER PURCHASED ON TOTALDESCRIPTION DATE

SHARES IN NAME OF VALUATION SHARE MARGIN OR PLEDGED VALUE

RETIREMENT ACCOUNTS

NO.OF REGISTERED SOURCE OF PRICE PER TOTALDESCRIPTION DATE

SHARES IN NAME OF VALUATION SHARE VALUE

TOTAL

%

% %

%

%

%

%

& LOANS

BALANCE PAYMENT AMT.