Personal Financial Statement
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1
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3Personal Financial Statement
Name
Address
City, State, Zip
Phone Number
Date of Birth
Information current as of:
Own
Rent
This statement represents (initial)
Employer
Since MO/YR
Separate Property of Maker
Community Prop. - Maker & Spouse
Occupation
Bus. Phone
Social Security Number
Driver's License Number & State Issued
Partner, Officer or Director in another venture?
Are any assets pledged?
Have you ever made a composition settlement or filed bankruptcy? Please explain:
ASSETS
LIABILITIES AND NET WORTH
Cash on hand and in Banks (Schedule 1)
Notes Payable to Banks - Secured (Sch. 1)
US Government Securities
Unsecured (Sch. 1)
Accounts, Loans and Notes Receivable (Sch. 2)
Notes Payable to Relatives
Cash Surrender Value Life Insurance (Sch. 3)
Accounts and Notes Payable to Others
Other Stocks and Bonds (Sch. 4)
Rents and Interest Due
Real Estate (Sch. 5)
Taxes Due (Sch. 5)
Automobiles - Number (
)
Liens on Real Estate (Sch. 5)
Other Assets (Itemize below)
Finance Company Reference (8)
Other Liabilities (Itemize below)
TOTAL LIABILITIES
TOTAL NET WORTH
TOTAL ASSETS:
TOTAL LIABILITIES AND NET WORTH
CONTINGENT LIABILITIES
AMOUNT
TYPE OF CONTINGENCY
MAKER OF DEBT
As Guarantor
As Endorser or Co-Maker
On Leases and Contracts
Legal Claims
Provision for Federal Income Tax
Other Special Debt
(see other side)
2-28-2014
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Parent category: Financial