Consumer Debtor Financial Statement Template
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4Consumer Debtor Financial Statement
Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply.
1 Debtor(s) name(s) and address
2 Home phone number
3 Marital status
4a Debtor’s social security number
4b Spouse’s social security number
Section I
Employment Information
5 Debtor employer or business (name and address)
a How long employed
b Business phone number
c Occupation
(
)
d Number of exemptions
e Pay period:
f (Check appropriate box)
claimed on Form W-4
Weekly
Bi-weekly
Wage earner
…………..
Monthly
Sole proprietor
Payday………………….(Mon-Sun)
Partner
6 Spouse’s employer or business (name and address)
a How long employed
b Business phone number
c Occupation
(
)
d Number of exemptions
e Pay period:
f (Check appropriate box)
claimed on Form W-4
Weekly
Bi-weekly
Wage earner
…………..
Monthly
Sole proprietor
Payday………………….(Mon-Sun)
Partner
Section II Personal Information
7
Name, address and telephone number of next of kin or
8 Other names or alias
9 Previous address(es)
other relative
10
Age and relationship of dependents living in your household (exclude yourself and spouse)
Section III General Financial Information
11 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.) Enter bank loans in item 27.
Name of Institution
Address
Type of Account
Account No.
Balance
►
Total (Enter in item 20)………………………………………………………………………………………………………..……
12
Charge card lines of credit from banks, credit unions, and savings and loans. List all other charge accounts in item 27.
Type of Account
Name and Address
Monthly
Credit
Amount
Credit
or Card
of Financial Institution
Payment
Limit
Owed
Available
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