Personal Financial Statement
CONFIDENTIAL
Name Name
Residence Address Residence Address
City, State & Zip City, State & Zip
Employer Employer
Position or Occupation Position or Occupation
Business Address Business Address
City, State & Zip City, State & Zip
Res. Phone Res. Phone
Social Security Number Social Security Number
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
If so, please describe:
YES NO
SOURCES OF INCOME FOR YEAR ENDED:
CONTINGENT LIABILITIES
Debts Owed To Banks (Detailed in Schedule C)
PERSONAL INFORMATION
Debts And Accounts Owed To Others
(Detailed in Schedule D)
Total Liabilities
If so, name of executor:
Do you have a will?
Net Worth
Are you a partner or officer in any other venture?
Cash Value Of Life Insurance (Detailed in Schedule E)
Real Estate (Detailed In Schedule B)
Stocks And Bonds (Detailed in Schedule A)
Inventory, Merchandise, Unsold Farm Products, Etc.
Notes And Accounts Due Me (Collectable)
Automobile
Make Model Year
Real Estate Income
Total Liabilities And Net Worth
If so, please describe:
SECTION 1-INDIVIDUAL INFORMATION (Type or Print) SECTION 2-OTHER PARTY INFORMATION (Type or Print)
Other Liabilities: (Please List)
Cell #
Real Estate Mortgages (Detailed in Schedule B)
ASSETS
Cash On Hand And In Banks
As endorser, co-maker or guarantor?
On leases or contracts?
Legal Claims:
Other special debt:
D.O.B.
Other Assets: (Please List)
Livestock
Machinery And Equipment
Amount of contested income tax liens:
If so, please describe:
Cell #
Total Amount of Income from Sources
Are you obligated to pay alimony, child support,
or separate maintenance payments?
If so, please describe:
Income Tax settled through (date):
Are you a defendant in any suits or legal action:
income need not be revealed if you do not wish to have it
considered as a basis for repaying this obligation)
Do you have any contingent liabilities?
Total Assets
Other Income
(Alimony, child support, or separate maintenance
If so, please describe
Salary, Bonuses & Commissions
Dividends
Have you ever declared bankruptcy?
Personal bank accounts carried at:
Any assets pledged other than as described on schedules?
D.O.B.
SECTION 3-STATEMENT OF FINANCIAL CONDITION (Complete Reverse Side)
LIABILITIES
If so, please describe:
