Form Mdes - 1852 - Personal Financial Statement Page 2
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1
2: List the name and address of each organization in which you
STOCKS, BONDS, MUTUAL FUNDS, ANNUITIES, DIVIDENDS
have investment/ownership as well as amount and value of your investment/ownership. If more than two, list additional
investments on a separate piece of paper.
Name & Address of the Organization
Type of
Number of
Market Value
Investment
Shares/Units
:
OTHER PROPERTY
Safe Deposit Boxes _____________________________________________________________________________________
List Location
Box Number
Contents
Insurance _____________________________________________________________________________________________
List Company
Policy Number
Cash Surrender Value
Automobile ____________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Automobile ____________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Recreational Vehicle ____________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Boat _________________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Trailer ________________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Snowmobile ___________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
Other _________________________________________________________________________________________________
Year
Make
License Number
Cost
Loan Balance
:
List all funds
: List all household
MONTHLY HOUSEHOLD INCOME
MONTHLY HOUSEHOLD EXPENSES
coming into your household.
expenses. If you fill in an amount for “Other”, you must
Number of members in your household _______
attach a separate sheet giving a breakdown of this amount
by name of creditor, account number, total amount due,
APPLICANT
SPOUSE
OTHER
and monthly payment.
Wages
Or
EXPENSE ITEM
MONTHLY AMOUNT
Salaries
Rent or Mortgage
Self
Food
employment
Utilities
Other
(Explain)
Automobile
Taxes
TOTAL MONTHLY INCOME $__________________
(Real estate/Personal)
Alimony/Child Support
TOTAL MONTHLY EXPENSES $________________
Medical
DECLARATION: I declare that to the best of my knowledge
and belief, this financial statement is true and correct. I authorize
the Commissioner of Economic Security or the delegated
Insurance
representative to verify any of the information contained on this
form.
Other
____________________________________________________
Applicant’s Signature
Date
____________________________________________________
Spouse’s Signature
Date
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