Personal Financial Statement Template - United Casualty And Surety Insurance Company Page 2
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1
2SCHEDULE “A” STOCKS AND BONDS
Description
Par Value
Market or Forced
Pledged to Secure
Sale Value
.............................................................................................
$
$
$
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................
Total ........................
$
$
$
SCHEDULE “C” REAL ESTATE
Location and Description of Property
In Whose Name
Mortgagee
Present Forced
Amount of
Is Title?
Lender/Bank
Sale Value
Mortgage
.........................................................................
$
$
.........................................................................
.........................................................................
.........................................................................
.........................................................................
.........................................................................
.........................................................................
.........................................................................
.........................................................................
...................................................................................
Total .........................
$
$
Salary, bonuses & commissions $ ...........................................................................................................................
Dividends
$ ...................................................................................................................................
Real Estate Income
$ ...................................................................................................................................
Other Income
.....................................................................................................................................
Are any assets owned/held by a trust ? Which ? .....................................................................................................
Do You Have A Will ?
.....................................................................................................................................
Are You A Partner or Officer In Any Other Venture ? ..............................................................................................
Are You Presently A Defendant In Any Lawsuits or Litigation ? ..............................................................................
Have You Ever Been Declared Bankrupt ? .............................................................................................................
Personal Federal & State Income Taxes Settled Through (Date) ............................................................................
The maker of the foregoing statement hereby authorizes United Casualty and Surety Insurance Company to verify any information provided and
obtain credit reports. The undersigned hereby certifies that each statement hereinbefore contained is true and that this statement is made for the
purpose of inducing United Casualty and Surety Insurance Company to execute certain bonds or undertakings.
Dated
Signature
X ______________________________________________________
Social Security #
______________________________________________________
Print Name
______________________________________________________
Signature
X ______________________________________________________
Social Security #
______________________________________________________
Print Name
______________________________________________________
68-1119S (9/98)
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