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PERSONAL FINANCIAL STATEMENT

Print Name:__________________________________________________________________________

Street Address:_______________________________________________________________________
City:______________________________ State:_____________________ zip code:_______________

Home Phone:______________ Bussiness Phone:_________________ Email:_____________________

ASSETS: LIABILITIES:
Cash on hand & banks: $________________________ Due to Banks (Loans)
Certificates of Deposit:$________________________ Name of Bank(s)
Money Market Funds:$_________________________ _______________ $___________________
Stocks & Bonds:$_____________________________ _______________ $____________________
Account/Notes Receivable:$_____________________

Vested Portion of Pension or Real Estate Mortgages
Profit Sharing:$_______________________________ Home:$____________________________
Condos, Farm, Etc.:$__________________
Cash Value of Life Insurance:$____________________ Real Estate Taxes due:$_________________

Real Estate Owned: Bank Loans – Automobile:
Home:$______________________________________ _____________: $_____________________
Apartments, Condo’s:$__________________________ _____________: $_____________________
Farm, Business:$______________________________
Credit Card Balances:
Other Assets (Itemized): ___________$_______________________
__________________:$__________________________ ___________$_______________________
__________________:$__________________________

Automobiles:$__________________________________ Other Debts:
Furniture’s:$____________________________________ (e.g. Health, Life Insurance, Money Owed
to
Fixtures, Machineries & Tools:$____________________ Individuals,)
Others:$_______________________________________ ____________$_____________________
____________$_____________________
____________$_____________________
TOTAL ASSETS (A):$________________________ (B):$______________________________
TOTAL ASSETS (A) LESS TOTAL LIABILITIES (B):= $__________________ (C) NETT WORTH
PRESENT ANNUAL INCOME FROM ALL SOURCES: $___________________________________

Signature(s)_________________________________. ________________________________________
Date:______________________________________ Date:____________________________________