Personal Financial Statement Template Page 2
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2Section 3. Stocks and Bonds.
(Top three investment by value.)
Number of
Name of Issuer of
Market Value
Date of
Cost
Total Value
Shares
Securities
Quotation / Exchange
Quotation / Exchange
Section 4. Real Estate Owned.
(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
of this statement and signed.)
Property A
Property B
Property C
Type of Property
Address
Date of Purchase
Original Cost
$
$
$
Present Market Value
Name & Address
(Mortgage Holder)
Mortgage Account
Number
Mortgage Balance
$
$
$
Amount of Payment
Month:
Year:
Month:
Year:
Month:
Year:
(Month / Year)
$
$
$
$
$
$
Section 5. Other Personal Property and Other Assets.
(Describe, and if any is pledged as security, state name and address of
lien holder, amount of lien, terms of payment, and if delinquent, describe delinquency.)
Section 6. Unpaid Taxes.
(Describe in detail, including type, to whom payable, when due, amount, as to what property, and if delinquent,
describe delinquency.)
Section 7. Other Liabilities.
(Describe in detail.)
Section 8. Life Insurance Held.
(Give face amount, cash surrender value of policies, name of insurance company, and beneficiaries.)
I HEREBY REPRESENT AND WARRANT THAT THE FOREGOING INFORMATION CONTAINED IN THIS FINANCIAL STATEMENT, AND ANY
INFORMATION PROVIDED IN CONNECTION WITH IT, IS TRUE AND CORRECT AND PRESENTS FAIRLY IN ALL MATERIAL RESPECTS MY
FINANCIAL CONDITION. I HEREBY IRREVOCABLY AND CONTINUOUSLY AUTHORIZE ALLY FINANCIAL INC. (ALLY) TO OBTAIN FROM
AND PROVIDE TO THIRD PERSONS, FROM TIME TO TIME, ANY AND ALL PERSONAL, FINANCIAL, BUSINESS AND OTHER
INFORMATION ABOUT ME TO INVESTIGATE THE INFORMATION IN THIS FINANCIAL STATEMENT AND TO ASSES MY CREDIT
WORTHINESS (INCLUDING OBTAINING A CONSUMER CREDIT REPORT). FURTHER, I PROMISE TO NOTIFY ALLY IMMEDIATELY (A) IF
MY NET WORTH AS SHOWN ON THIS FINANCIAL STATEMENT DECLINES BY 25%. (B) IF MY CONTINGENT LIABILITY, AS RECORDED,
INCREASES BY 25% OF MY NET WORTH OR (C) IF A COMBINATION OF NET WORTH DECLINE AND CONTINGENT LIABILTY INCREASE,
TOTALS 25% OF MY NET WORTH.
Signature:
Date:
Social Security Number:
Signature:
Date:
Social Security Number:
2
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