Consumer Debtor Financial Statement Template (Page 2 of 4) in pdf

►

Totals (Enter in item 26)

Section III (continued) General Financial Information

13 Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)

14 Real Property (Brief description and type of ownership)

Physical Address

County …………………..

15 Life Insurance (Name of Company)

Policy Number

Type

Face Amount

Available Loan Value

Whole

Term

Whole

Term

Whole

Term

►

Total (Enter in item 22)

16 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.):

Kind

Quantity or

Current

Where

Owner

Denomination

Value

Located

of Record

17 Other information relating to your financial condition. If you check the “Yes” box, please give dates and explain on page 4, Additional Information or Comments:

a Court proceedings

Yes

b Bankruptcies

Yes

c Repossessions

Yes

d Recent sale or other transfer of assets less than full value

Yes

e Anticipated increase in income

Yes

f Participant or beneficiary to trusts, estate, profit sharing, etc.

Yes

18 Taxes

a Did you file a Federal Income Tax Return last year?

_________ Yes

_________ No

Joint _________

Individual __________

Amount of Gross Income on return was _____________________

b Are you or did you receive a tax refund from Federal, State, City or County? ________ Yes

________ No If yes, list from whom and amount of each refund:

Entity: _______________________________________________________________________________

$ _____________________________

Entity: _______________________________________________________________________________

$ _____________________________

c Do you owe delinquent taxes? ________ Yes

__________ No If yes, list below years and amounts due:

___________________________________________________________________________________________________________

Consumer Debtor Financial Statement Template Page 2

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