Personal Financial Statement Page 2
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2SCHEDULES
PAGE 2
No. 1 Banking Relations. (A list of all my bank savings and loan accounts.)
Name and Location
Cash Balance
Amount of Loan
Maturity of Loan
How Endorsed, Guaranteed or Secured
$
$
$
$
$
$
$
$
$
$
No. 2 Accounts, Loans and Notes Receivable. (A list of the largest amounts owing to me.)
Date Payment
Name and Address of Debtor
Amount Owing
Age of Debt
Description or Nature of Debt
Description of Security Held
Expected
$
$
$
$
$
$
No. 3 Life Insurance.
Face
Total Cash
Total Loans
Amount of
Type of
Is Policy
Name of Person Insured
Name of Beneficiary
Name of Insurance Co.
Amount
Surrender
Yearly
Yearly
Policy
Assigned?
of Policy
Value
Policy
Premium
$
$
$
$
$
$
$
$
$
$
$
$
No. 4 Other Stocks and Bonds.
Face Value Bonds
Present
Income Received
If Pledged
Description of Security
Registered in Name of
Cost
No. Stock Shares
Market Value
Last Year
State to Whom
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
No. 5 Real Estate. The legal and equitable title to all the real estate listed in this statement is solely in the name
of the undersigned, except as follows:
Due Dates &
Unpaid Taxes
Dimensions
Mortgages
Assessed
Present
Description or Street No.
Improvements Consist of
Amounts of
or Acres
or Liens
Value
Market Value
Year
Amt.
Payments
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
The undersigned certifies that the information inserted on both pages hereof has been carefully read and is
true and correct.
Date: _____________________________
Signed: __________________________________________
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