Personal Financial Statement Template
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4PERSONAL FINANCIAL STATEMENT AS OF
Date
C.H.KAUFFMAN & ASSOCIATES, INC.
Submitted to:
PERSONAL INFORMATION
PERSONAL INFORMATION
Applicant (Name)
Co-Applicant (Name)
Employer
Employer
Address of Employer
Address of Employer
Business Phone No.
No. of Years with Employer
Title/Position
Business Phone No.
No. of Years with Employer
Title/Position
Name of previous employer & position (if with current employer less
No. of Yrs.
Name of previous emplyer & position (if with current employer less than 3 yrs.) No. of Yrs.
than 3 yrs.)
Home Adress
Home Adress
Home Phone No.
Social Security No.
Date of Birth
Home Phone No.
Social Security No.
Date of Birth
Name, Phone No. of your Accountant
Name, Phone No. of your Accountant
Name, Phone No. of your Attorney
Name, Phone No. of your Attorney
Name, Phone No. of your Investment Advisor/Broker
Name, Phone No. of your Investment Advisor/Broker
Name, Phone No. of your Insurance Advisor
Name, Phone No. of your Insurance Advisor
Cash Income & Expenditures Statement for Year Ended
(Omit cents)
ANNUAL INCOME
AMOUNT ($)
ANNUAL EXPENDITURES
AMOUNT ($)
Salary (applicant)
Federal Income and Other Taxes
Salary (co-applicant)
State Income and Other Taxes
Bonuses & Commissions (applicant)
Rental Payments, Co-op or Condo Maintenance
Bonuses & Commissions (co-applicant)
Mortgage Payments (Residential)
Rental Income
Mortgage Payments (Investment)
Interest Income
Property Taxes (Residential)
Dividend Income
Property Taxes (Investment)
Capital Gains
Interest & Principal Payments on Loans
Partnership Income
Insurance
Other Investment Income
Investments (including tax shelters)
Other Income (List)**
Alimony / Child Support
Tuition
Other Living Expenses
Medical Expenses
Other Expenses (List)
TOTAL INCOME
TOTAL EXPENDITURES
$
-
$
-
Any significant changes expected in the next 12 months?
Yes
No
(If yes, attach information.)
** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant or co-applicant does not wish to have
it considered as a basis for repaying this obligation
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