Personal Financial Statement Template - United Casualty And Surety Insurance Company
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1
2Submitted to:
United Casualty and Surety Insurance Company
PERSONAL FINANCIAL STATEMENT
Name:
Name of Individual and Spouse (if married)
Home Address
Statement of Assets and Liabilities as of
CURRENT ASSETS
CURRENT LIABILITIES
Total $
Cash on hand (not in bank) ...........................
$
Notes Payable, Bank .... ($
Monthly)
Total
Cash in following banks
Notes Payable, Bank .... ($
Monthly)
............................................................
Notes Payable, Other:
Total
............................................................
............................. ($
Monthly)
Total
............................................................
............................. ($
Monthly)
Total
Accounts Receivable ....................................
............................. ($
Monthly)
............................................................
Accounts Payable .....................................
Stocks, Bonds and other securities listed
...................................................................
In Schedules “A” .........................................
...................................................................
…………………………………………………
Other Current Liabilities-Credit Cards:
………..…………………………….………….
.........................................................
…………………………………….……………
.........................................................
Notes Receivable .........................................
.........................................................
Other current assets:
Cash Value Life Ins. (not face value) ...........
Total Current Liabilities: .........................
$
............................................................
............................................................
LONG TERM LIABILITIES
Total Current Assets ..................................
$
Total
Mortgages on Real Estate ($ __
Monthly)
Schedule “C” ...........................................
Other Debts maturing in a year or more.
.........................................................
FIXED ASSETS
.........................................................
......................................................................
.........................................................
Furniture and Fixtures ..................................
.........................................................
Real Estate (complete schedule “C”) .............
$
Total Long Term Liabilities
Homestead .................................................
$
Total Liabilities ........................................
Investment ..................................................
Business .....................................................
NET WORTH
Other ...........................................................
Net Worth (Assets minus Liabilities) ..........
Other Fixed Assets:
...................................................................
............................................................
...................................................................
............................................................
...................................................................
............................................................
...................................................................
Long Term Receivables
............................................................
$
$
Total Fixed Assets ......................................
Total Net Worth ........................................
Total of all Assets ........................................
$
Total of All Liabilities & Net Worth ............
$
68-1119S (9/98)
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