Form Ub-092-A Forff - Confidential Financial Statement Page 2
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3UB-092-A FORFF (4-17) – Page 2
LIST ALL YOUR MONTHLY EXPENSES:
Do you:
Own
Rent
Name of Mortgage Holder / Landlord:
Mortgage Holder / Landlord’s Address (No., Street, P.O. Box)
City
State
ZIP Code
Monthly Rental / Mortgage Amount: $
If you own, equity value: $
Monthly Utilities: $
Monthly Medical: $
Monthly Food Expense: $
(Electric, gas, water sewer, trash, telephone)
(Medicines, insurance premiums, etc.)
Other Expenses: $
Specify:
LIST ALL OTHER MONTHLY BILLS (finance company, department stores, credit cards, etc.):
Name of Company
Company Address (No., Street, P.O. Box)
City
State
ZIP Code
Original Balance: $
Balance Owed: $
Monthly Payment: $
Name of Company
Company Address (No., Street, P.O. Box)
City
State
ZIP Code
Original Balance: $
Balance Owed: $
Monthly Payment: $
LIST ALL BANK ACCOUNTS:
Name of Bank / Financial Institution
Bank / Financial Institution Address (No., Street)
City
State
ZIP Code
Type of account:
Checking
Savings
Certificate of Deposits
Other:
Account Number:
Value of Account: $
Name of Bank / Financial Institution
Bank / Financial Institution Address (No., Street)
City
State
ZIP Code
Type of account:
Checking
Savings
Certificate of Deposits
Other:
Account Number:
Value of Account: $
LIST ALL VEHICLES, BOATS AND RECREATIONAL VEHICLES:
Make and Model
Year
License Plate #
Value: $
Monthly Payment: $
Amount Owed: $
Make and Model
Year
License Plate #
Value: $
Monthly Payment: $
Amount Owed: $
Make and Model
Year
License Plate #
Value: $
Monthly Payment: $
Amount Owed: $
Make and Model
Year
License Plate #
Value: $
Monthly Payment: $
Amount Owed: $
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Parent category: Legal