Personal Financial Statement Template Page 2
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1
2
3Section 4 – Annual Income for Year Ended
Individual
Joint
Annual
Individual
Joint
Contingent Liabilities
Individual
Joint
Expenditures
Estimated Amount
Salary, bonuses &
Mortgage/rental
Do you have any …
commissions
payments
Yes No
Dividends & interest
Real Estate taxes &
Contingent liabilities (as
assessments
Endorser, co-maker or
Guarantor?)
Real Estate income
Taxes-federal, state
On leases? Contracts?
& local
Other Income (alimony,
Insurance payments
Involvement in pending
child support or separate
Legal actions?
Maintenance income need
Other contract pay-
Contested income tax
not be revealed if you do
ments (car pay-
Liens?
not wish to have it con-
ments, charge cards)
sidered as a basis for re-
Alimony, child sup-
Any estimated capital
paying this obligation)
port, maintenance
gains tax on unrealized
Asset appreciation?
Other expenses
Other special debt or
Circumstances?
Total Income
$
Total Expenditures
$
If yes to any question(s)
describe:
Total Contingent
$
Liabilities
(COMPLETE SCHEDULES AND SIGN ON REVERSE SIDE)
SCHEDULE A – CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.
Name of Financial Institution
Type of Account
Owner
(J)
If Pledged, to whom?
Balance
SCHEDULE B – U.S. GOVERNMENT & MARKETABLE SECURITIES (Use additional sheet if necessary)
Number of Shares
Description
In Name of
Are these registered,
Market
Exchanges where
or Face Value of
pledged or held by
Value
traded
Bonds
others?
SCHEDULE C – NON-MARKETABLE SECURITIES (Use additional sheet if necessary)
Number of Shares
Description
In Name of
Are these registered,
Market
Exchanges where
or Face Value of
pledged or held by
Value
traded
Bonds
others?
SCHEDULE D – INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary)
Description/Locati
(J)
Date of Original
% Owned
Market Value
Present
Monthly
Mortgage
Mortgage Owed To
on of Real Estate
Investment/Amount
by You
of Your % of
Balance
Payment
Maturity
Investment
Investment
Date
SCHEDULE E – LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE
Name of Insurance
Owner of Policy
Beneficiary and
Face Amount
Policy Loans
Cash Surrender
Company
Relationship
Value
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