Unisa Loan Servicing For Higher Education Page 2

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FINANCIAL STATEMENT
TO BE COMPLETED BY BORROWER
1.
Marital Status: (
)
check one
______Single _____ Widow(er) _____ Married _____ Divorced or Separated
2.
DEPENDENTS:
Name
Relationship
Age
Name
Relationship
Age
________________
__________
___
________________
__________
___
________________
__________
___
________________
__________
___
3.
MONTHLY INCOME / MONTHLY EXPENSES:
MONTHLY INCOME
Gross Monthly Income
_________________
Deductions
_________________
Net Monthly Income
_________________
Spouse’s Net Monthly Income
_________________
Monthly Public Assistance (list type) ______________
_________________
Monthly Support Income (if separated or divorced)
_________________
Other Income (list type) ________________________
_________________
TOTAL MONTHLY INCOME
_________________
MONTHLY EXPENSES
Balance Outstanding
Monthly Payments
Mortgage / Rent
__________________
_________________
Car Expenses
__________________
_________________
Medical / Dental Insurance
__________________
_________________
Insurance Other
__________________
_________________
Bank Loans (list type):
_____________________
__________________
_________________
_____________________
__________________
_________________
_____________________
__________________
_________________
Credit Cards (list):
_____________________
__________________
_________________
_____________________
__________________
_________________
_____________________
__________________
_________________
Utilities
__________________
_________________
Telephone
__________________
_________________
Monthly Support Payments
__________________
_________________
Food
_________________
Other Expenses:
_____________________
__________________
_________________
_____________________
__________________
_________________
TOTAL MONTHLY EXPENSES
_________________
TOTAL MONTHLY INCOME- EXPENSES EQUALS
_________________
Assets:
Savings Account Balance (Bank Name)
___________________ _________________
Checking Account Balance (Bank Name)
__________________ _________________
4.
LIST BELOW THE CIRCUMSTANCES OF YOUR PRESENT FINANCIAL STATUS:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
5.
EMPLOYMENT INFORMATION:
Employer Name:
_____________________________________________
Employer Address:
_____________________________________________
Employer Phone:
_____________________________________________

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