Financial Information Statement - Kansas Department Of Revenue Page 2
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5Section III
Vehicle Information
Vehicle Information
13. List all vehicles
A.
Year
VIN #
Bal. Owed
Loan begin date
Name and address of Lender
Make
$
Market Value
Loan end date
Model
Tag #
$
Monthly Payment
Equity in Assets
$
Date of last payment made
$
B
Year
VIN #
Bal. Owed
Loan begin date
Name and address of Lender
Make
$
Market Value
Loan end date
Model
Tag #
$
Monthly Payment
Equity in Assets
$
Date of last payment made
$
C.
Year
VIN #
Bal. Owed
Loan begin date
Name and address of Lender
Make
$
Market Value
Loan end date
Model
Tag #
$
Monthly Payment
Equity in Assets
$
Date of last payment made
$
D.
Year
VIN #
Bal. Owed
Loan begin date
Name and address of Lender
Make
$
Market Value
Loan end date
Model
Tag #
$
Monthly Payment
Equity in Assets
$
Date of last payment made
$
SECTION IV
Bank accounts (including savings & loans, credit Unions, IRA and retirement plan,certificates of deposit, etc.
14. Name/Address of Institution or Bank
Type of Account
Account Number
Balance (monthly average)
15. Life Insurance Information
Policy No.
Type
Face Amount
Available Loan Value
Whole
Term
Whole
Term
Whole
Term
Whole
Term
16. Major credit cards, bank cards and lines of credit from banks, credit unions and savings and loans
Name / Address
Type of Account
Monthly
Credit
Amount
Credit
of Financial Institution
or Card
payment
Limit
Owed
Available
TOTAL
17 Safe deposit boxes rented or access (List all locations, box number, and contents)
Page 2
revised 11/2011
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