Form 12a638 - Statement Of Financial Condition For Individuals July 2004

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12A638 (7-04)
STATEMENT OF FINANCIAL CONDITION
If additional space is needed,
Commonwealth of Kentucky
attach separate sheet.
FOR INDIVIDUALS
DEPARTMENT OF REVENUE
(
1. Your Name and Address (including county)
2. Home Phone No.
3. Marital Status
4. No. in Household
(
)
1a. Date of Birth
1b. Soc. Sec. No.
5a. Spouse’s Name and Date of Birth
5b. Spouse’s Soc. Sec. No.
SECTION I—EMPLOYMENT INFORMATION
6. Your Employer or Business (name and address)
7. Business Phone Number
8. Occupation
(
)
10. (Check appropriate box)
o
o
o
o
o
o
o
9. Pay Basis:
Weekly
Monthly
Other
Employee
Partner
Sole Proprietor
Corporate Officer
11. Spouse’s Employer or Business (name and address)
12. Business Phone No.
13. Occupation
(
)
15. (Check appropriate box)
o
o
o
o
o
o
o
14. Pay Basis:
Weekly
Monthly
Other
Employee
Partner
Sole Proprietor
Corporate Officer
SECTION II—ASSETS
Account
Assets
Name and Address of Institution
Type of Account
Account No.
Balance
16. Bank Accounts
(include savings and
loans, credit unions,
IRA and KEOGH
accounts, certificates
of deposits, etc.)
17. Stocks, Bonds,
Investments
18. Cash
19. Bank Revolving Credit
20. Cash or Loan Value of
Life Insurance
Description and Type of Ownership
Address
Current Market Value
Balance Due
21. Vehicles (model, year,
a.
license no.)
b.
c.
22. Real Property
a.
b.
c.
d.
23. Other Assets
a.
b.

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