Consumer Debtor Financial Statement Template Page 3
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1
2
3
4Section IV Assets and Liabilities
Current
Current
Equity
Amount
Date of
Description
Market
Amount
In
of
Name and Address of
Date
Final
Value
Owed
Asset
Monthly
Lien/Note Holder/Lender
Pledged
Payment
Payment
19 Cash
20 Bank Accounts (from item 11)
21 Securities (from item 16)
22 Cash or loan value of insurance
23 Vehicles (model, year, license, tag #)
a
b
c
24
Real
a
Property
(from
b
Section III,
Item 14)
c
25 Other assets
a
b
c
d
e
26 Bank revolving credit (from item 12)
27
Other
a
Liabilities
(including
b
bank loans,
judgements,
c
notes, and
charge
accounts
d
not entered
in item 11)
e
f
g
28 Federal taxes owed (prior years)
29 Totals
$
$
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