Personal Financial Statement
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1
2PERSONAL FINANCIAL STATEMENT
As of the__________day of_______________________, 2011
Name
To
Address
For the purpose of securing credit from time to time with you. I furnish the following as a true and correct statement of
my financial condition on date named above, and agree to notify you of any material changes affecting my financial
condition. In the absence of such notice, this is to be considered a continuing statement and my ability to pay has not
fallen below the condition herein set forth.
ASSETS
LIABILITES
Cash (Schedule A)
$
Notes Payable to Banks (Schedule A)
$
Stocks and Bonds
Notes Payable to Relatives (Schedule E)
Accounts and Notes Receivable
Notes Payable to Others (Schedule E)
Due from relatives and friends
Accounts Payable
Due from others – good
Federal & State Income Taxes Payable
Doubtful
Other Accrued Taxes & Interest
Real Estate Owned (Schedule C)
Mortgages Payable (Schedule C)
Mortgages Owned (Schedule D)
Installment Contracts Payable
Cash Surrender Value Life Ins. (Schedule F)
Loans against Life Insurance (Schedule F)
Other Assets (itemize):
Other Liabilities (itemize):
TOTAL LIABILITES
NET WORTH
TOTAL $
TOTAL
$
Amount of Assets Pledged
$
Amount of Liabilities Secured
$
Annual Income: Salary $
Fees or Commissions $
Other $
Business or Occupation
Name of Employer
Are you a partner or officer in any other business venture?
Spouse’s Name
Age?
Marital Status?
No. of Dependents
(
single, married, widow(er) or divorced)
Are there any unsatisfied judgements or legal actions pending against you?
Have you ever gone through bankruptcy or made a general assignment?
As of the date of this financial statement, I had not pledged, assigned, hypothecated or transferred the title to any of my assets, except as
noted on this form or on a supporting schedule, nor has any such action been taken since that date, except as follows (give details):
CONTINGENT LIABILITIES: As endorser or co-maker
On receivable discounted or sold
As guarantor
On leases, mortgages or contracts
Unsettled claims
Other (itemize)
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