Personal Financial Statement Template Page 2
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1
2SCHEDULE A - U. S. GOVERNMENT & MARKETABLE
SECURITIES
Number of
Shares
Are
These
Market
Description
In Name Of
or Face Value
(Bonds)
Pledged?
Value
Enter Sec. C Line
2
SCHEDULE B - NON-MARKETABLE SECURITIES
Are
These
Source
of
Number of Shares
Description
In Name Of
Value
Pledged?
Value
Enter Sec C. Line
3
SCHEDULE C - PARTIAL INTERESTS IN REAL ESTATE
EQUITIES
Address &
Type
Title
In
%
Of
Date
Market
Mortgage
Mortgage
Cost
Of Property
Name Of
Ownership
Acquired
Value
Maturity
Amount
Enter Sec. C Line
6
SCHEDULE D - REAL ESTATE
OWNED
Address &
Type
Title
In
Date
Market
Mortgage
Mortgage
Cost
Of Property
Name Of
Acquired
Value
Maturity
Amount
Enter Sec. C Line
7
SCHEDULE E - LIFE INSURANCE CARRIED, INCLUDING N.S.L.I. AND GROUP
INSURANCE
Name
Of
Owner
Of
Face
Policy
Cash
Surrender
Beneficiary
Insurance Company
Policy
Amount
Loans
Value
Enter Sec. C Line
10
SCHEDULE F - RETIREMENT ACCOUNTS (IRA'S, 401K,
ETC.)
Name of Financial
Institution
Amount
Description
SCHEDULE G - BANKS OR FINANCE COMPANIES WHERE CREDIT HAS BEEN
OBTAINED
Name & Address
Credit
In
Secured Or
Original
High
Current
Of Lender
The Name Of
Unsecured?
Date
Credit
Balance
SECTION D - SECURED CREDIT (Complete only if credit is to be secured.)
Briefly describe the property to be given as
security:
and list names and addresses of all co-owners of the
property:
Name
Address
If the security is real estate, give the full name of co-owner (if
any):
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Signature
(Individual)
Signature
(Individual)
S.S. No.
Date of
Birth
S.S. No.
Date of
Birth
Driver's License #
Driver's License #
Date
Signed
Date
Signed
Page 2 of
2
PFINSTAT
(2/2/2006)
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