Personal Financial Statement Form - Tuttle & Traina Insurance Agency, Inc.
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3PERSONAL FINANCIAL STATEMENT
Statement of Assets & Liabilities For:_________________________________ Social Security No. _____________________
As of this:_____________________________ Day of: __________________________________________ , 20_________.
CURRENT ASSETS
CURRENT LIABILITIES
Cash on Hand
$: _______________
Notes Payable, Bank:____________ $:_________________
Cash in Banks
Notes Payable, Bank:____________ $:_________________
______________________________
$: _______________
Notes Payable, Other
______________________________
$: _______________
_____________________________
$:_________________
______________________________
$: _______________
_____________________________
$:_________________
Accounts Receivable
Account Payable
$:_________________
______________________________
$: _______________
Accruals
$:_________________
Stocks, Bonds & Other Securities
Taxes
$:_________________
Total From Schedule A - Page 2
$: _______________
Other Current Liabilities
Notes Receivable (Schedule A-1)
$: _______________
_____________________________
$:_________________
Cash Value Life Ins
$: _______________
_____________________________
$:_________________
Other Current Assets
_____________________________
$:_________________
______________________________
$:________________
_____________________________
$:_________________
TOTAL CURRENT ASSETS
$:________________
TOTAL CURRENT LIABILITIES $:_________________
FIXED ASSETS
DEFFERED LIABILITIES
Real Estate (Schedule B)
Mortgages (Schedule D)
Homestead _____________________
$:________________
Homestead, Bank:______________
$:_________________
Investment _____________________
$:________________
Investment, Bank:______________
$:_________________
Business _______________________ $:________________
Business:_____________________
$:_________________
Other:_________________________
$:________________
Other:________________________ $:_________________
Prepaid Expenses
$:________________
Other Debts Maturing 1 Year or More
Other Fixed Assets/Investments
Total From Schedule E
$:_________________
Total From Schedule C
$:________________
____________________________
$:_________________
______________________________
$:________________
____________________________
$:_________________
______________________________
$:________________
Borrowed From Life Insurance
$:_________________
Personal Property/Equipment
______________________________
$:________________
TOTAL DEFFERED LIABILITIES$:________________
______________________________
$:________________
______________________________
$:________________
TOTAL OF ALL LIABILITIES
$:_________________
______________________________
$:________________
NET WORTH
TOTAL FIXED ASSETS
$:________________
TOTAL NET WORTH
$:_________________
TOTAL OF ALL ASSETS
$:________________
TOT. LIABILITY & NET WORTH$:________________
The undersigned hereby certifies that each statement herein contained is true, and this statement is made for the purpose of inducing ___________________________ COMPANY
to become surety for the undersigned or to accept the undersigned as Indemnitor. Authority is granted to any firm, individual, or corporation, and any financial institution to furnish
information concerning the statements herein or pertaining to the Undersigned's financial standing, credit or manner of meeting obligations.
Signed by: __________________________________________________________
Date: _________________________________________________________________
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