Personal Financial Statement Template
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4PERSONAL FINANCIAL STATEMENT
AS
OF
Date
SUBMITTED TO:
PERSONAL
INFORMATION
APPLICANT
(NAME)
CO-APPLICANT (NAME)
Employer
Employer
Address of Employer
Address of Employer
Business Phone No.
No. of Years with
No. of Years with
Title/Position Employer
Title/Position
Business Phone No.
Employer
Name of previous employer & position (if with current employer less than 3 yrs.)
No. of Yrs.
Name of previous employer & position (if with current employer less than 3 yrs.)
No. of Yrs.
Home Address
Home Address
Home Phone No.
Social Security No.
Date of Birth
Home Phone No.
Social Security No.
Date of Birth
Name, Phone No. of your Accountant
Name, Phone No. of your Accountant
. Name, Phone No. of your Attorney
Name, Phone No. of your Attorney
Name, Phone No. of your Investment Advisor/Broker
Name, Phone No. of your Investment Advisor/Broker
Name, Phone No. of your Insurance Advisor
Name, Phone No. of your Insurance Advisor
Cash
Income & Expenditures Statement For Year Ended
(Omit cents)
AMOUNT ($)
ANNUAL EXPENDITURES
AMOUNT ($)
ANNUAL INCOME
$
$
Federal Income and Other Taxes
Salary (applicant)
Salary (co-applicant)
State Income and Other Taxes
Rental Payments, Co-op, or Condo Maintenance
Bonuses & Commissions (applicant)
Mortgage Payments
Bonuses & Commissions (co-applicant)
Residential
Investment
Property Taxes
Rental Income
Residential
Investment
Interest & Principal Payments on Loans
Interest Income
Dividend Income
Insurance
Capital Gains
Investments (including tax shelters)
Partnership Income
Alimony/Child Support
Other Investment Income
Tuition
Other Income (List)**
Other Living Expense
Medical Expenses
Other Expense (List)
$
$
TOTAL EXPENDITURES ►
TOTAL INCOME ►
Any significant changes expected in the next 12 months?
Yes
No (If yes, attach information).
** Income from alimony, child support, or separate maintenance income need not be revealed if the applicant
or co-applicant does not wish to have it considered as a basis for repaying this obligation.
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