Personal Financial Statement Template Page 2
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21. STOCKS AND BONDS
No.
If any pledged, State to Whom
Dividends Paid
Name of Security
Market Value
Shares
and for What Purpose
Last Two Years
TOTAL
$
2. ACCOUNTS RECEIVABLE
Name and Address (street and city) From Whom Due
For What Is It Due
When Sold
When Due
Amount
TOTAL
$
3. NOTES RECEIVABLE
Name and Address (street and city) From Whom Due
For What Due
How Secured
Date
Maturity
Amount
TOTAL
$
4. REAL ESTATE
Title in
Amount
Monthly
Monthly
Description of Property
Market Value
Cost
Name Of
Encumbrance
Payments
Income
TOTAL
$
$
$
$
5. EQUIPMENT
Age of
Monthly
Description and Capacity of Items
Market Value
Cost
Encumbrance
Item
Payment
TOTAL
$
$
$
6. LIFE INSURANCE – CASH VALUE
Name of Company
Policy Number
Name of Insured
Beneficiary
Face Value
Cash Value
Amount Borrowed
The maker of the foregoing or accompanying statement hereby authorizes the company to confirm the bank balances claimed and all other items comprising
said statement.
Dated ______________________________________, 20________
SIGNATURE:
ID-1256 (REV. 9/00) • PAGE 2 of 2
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