XERIC FOUNDATION

Financial Statement for Comic Book Artists

APPLICANT INFORMATION

APPLICANT'S NAME

APPLICANT'S ADDRESS

SOCIAL SECURITY NO.

DATE OF BIRTH

HOME PHONE NO.

YEARS AT RESIDENCE

OWN HOME RENT

PREVIOUS ADDRESS (if less than five years at current address)

APPLIED AND REVIEWED BEFORE? AND WHEN?  Yes No

MONTHLY MORTGAGE PAYMENT (Principal, Interest, Taxes, Insurance) $____________

MORTGAGE HOLDER/ LANDLORD NAME AND ADDRESS

EMPLOYER

POSITION

LENGTH OF EMPLOYMENT

EMPLOYER'S ADDRESS

ANNUAL SALARY (attach proof of income)* $______________

BUSINESS PHONE NO ( ____) ____-_________

PREVIOUS EMPLOYER

PREVIOUS EMPLOYER'S ADDRESS

If you do not wish to rely on income from alimony, child support, or separate maintenance payments, such income need not be revealed.

SOURCE OF OTHER INCOME

AMOUNT OF OTHER INCOME (attach proof of income)* $______________

CHECKING ACCOUNT BANK ________________________________________

SAVINGS ACCOUNT BANK _________________________________________

	CREDITOR NAME	MONTHLY PAYMENTS	BALANCE OWED
BANK CARD ACCOUNT	____________________	____________________	________________
DEPARTMENT STORE ACCOUNT	____________________	____________________	________________
INSTALLMENT LOAN ACCOUNT	____________________	____________________	________________
OTHER	____________________	____________________	________________

Are you legally responsible to pay alimony, child support or maintenance payments? If yes, monthly payment: $ ___________ Are you a cosigner, endorser, or guarantor? If yes, monthly payment: $ _____________

NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU

PHONE NO.

Notes:

* Use the reverse side to list additional assets and/or liabilities.

* Please attach a copy of your most recent paystub or W-2. If you are self-employed or unemployed, provide copies of your Federal tax returns for the last two years. If sending TAX RETURNS instead of paystub or W-2, send ONE copy only in a separate envelope. The contents will be shredded after the review.

OTHER ASSETS AND LIABILITIES

Assets:	Description	Value
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	TOTAL	_____________________________
Liabilities:	Description	Value
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	____________________________________________	_____________________________
	TOTAL	_____________________________

Notes: