PERSONAL FINANCIAL STATEMENT

Print Name:__________________________________________________________________________

Street Address:_______________________________________________________________________
City:______________________________ State:_____________________ zip code:_______________

Home Phone:______________ Bussiness Phone:_________________ Email:_____________________

ASSETS: LIABILITIES:
Cash on hand & banks: $________________________ Due to Banks (Loans)
Certificates of Deposit:$________________________ Name of Bank(s)
Money Market Funds:$_________________________ _______________ $___________________
Stocks & Bonds:$_____________________________ _______________ $____________________
Account/Notes Receivable:$_____________________

Vested Portion of Pension or Real Estate Mortgages

Profit Sharing:$_______________________________ Home:$____________________________
Condos, Farm, Etc.:$__________________
Cash Value of Life Insurance:$____________________ Real Estate Taxes due:$_________________

Real Estate Owned: Bank Loans – Automobile:

Home:$______________________________________
Apartments, Condo’s:$__________________________
Farm, Business:$______________________________
Other Assets (Itemized):
__________________:$__________________________
__________________:$__________________________
_____________: $_____________________
_____________: $_____________________
Credit Card Balances:
___________$_______________________
___________$_______________________

Automobiles:$__________________________________ Other Debts:

Furniture’s:$____________________________________ (e.g. Health, Life Insurance, Money Owed
to
Fixtures, Machineries & Tools:$____________________ Individuals,)
Others:$_______________________________________ ____________$_____________________
____________$_____________________
____________$_____________________
TOTAL ASSETS (A):$________________________ (B):$______________________________
TOTAL ASSETS (A) LESS TOTAL LIABILITIES (B):= $__________________ (C) NETT WORTH
PRESENT ANNUAL INCOME FROM ALL SOURCES: $___________________________________

Signature(s)_________________________________. ________________________________________
Date:______________________________________ Date:____________________________________