Personal Financial Statement
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1PERSONAL FINANCIAL STATEMENT
Answer all Questions, Use additional page if needed.
__________________________
___________________________________ ________________________
Applicant’s Name:
S.S. #:
Date:
CURRENT ASSETS
CURRENT LIABILITIES (From Credit Report)
Cash in __________________________
$_____________
Creditors
Name of Bank
Cash in __________________________
$_____________
1.
To_____________________ Bal. Due $____________
Name of Bank
2.
To_____________________ Bal. Due $____________
3.
To_____________________ Bal. Due $____________
Submit copy of current 3 months personal bank statements
4.
To_____________________ Bal. Due $____________
5.
To_____________________ Bal. Due $____________
Stocks, Bonds, etc. Market value
$ ____________
6.
To_____________________ Bal. Due $____________
Submit proof of value
Total
$ ____________
Past Due $ _________________________
Total
$_____________
Real Estate – Give locations and a copy of your current Tax
Assessment(s). You may also include a written appraisal to
Income taxes (Unpaid Balance)
prove property value. Provide a deed for out of state property.
Federal
$________________
State
$________________
Total
$________________
1._____________________________
$_____________
_____________________________
Open Judgments/ Liens
2. _____________________________
$_____________
Date & Description (on separate page)
_____________________________
1.
________________________ $___________________
Total
$_____________
2.
________________________ $___________________
Total
$___________________
Other Assets – For Vehicles – Copy of Title and printout of
Kelly Bluebook value must be provided. Other assets will be
considered at the discretion of the Commission.
Provide name of mortgage holder and Balance due.
1._____________________________
$_____________
1.
__________________________ $____________
_____________________________
2.
__________________________ $____________
3.
__________________________ $____________
2. _____________________________
$_____________
Total Mortgages
$____________
_____________________________
Other liabilities
Total
$_____________
1.
________________________ $______________
2.
________________________ $______________
Total Other Liabilities
$______________
Total Assets
$_____________
Total Liabilities
$_______________
Net Worth
$_______________
(Must be $20,000 or more)
(Assets minus Liabilities = net worth)
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Parent category: Financial