Personal Financial Statement
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1
2CONFIDENTIAL
PERSONAL FINANCIAL STATEMENT
Statement Date:
Personal Information
Name:
SSN:
Address:
Birthdate:
City, State Zip:
Dependents:
Home Telephone:
Business Telephone:
Section I
ASSETS
LIABILITIES
1
Cash on Hand & in Banks
21
Notes Due to Banks
2
Cash Value of Life Insurance
22
Notes Due to Relatives & Friends
3
U.S. Gov. Securities
23
Notes Due to Others
4
Other Marketable Securities
24
Accounts & Bills Payable
5
Notes & Accounts Receivable - Good
25
Unpaid Income Taxes Due - Federal State
6
26
Other Unpaid Taxes & Interest
Other Assets Readily Convertible to Cash - Itemize
7
27
Loans on Life Insurance Policies
8
28
Contract Accounts Payable
9
29
Cash Rent Owed
10
TOTAL CURRENT ASSETS
$0.00
30
Other Liabilities Due within 1 Year - Itemize
11
Real Estate Owned
31
12
Mortgages & Contracts Owned
32
13
Notes & Accounts Receivable - Doubtful
33
TOTAL CURRENT LIABILITIES
$0.00
14
Notes Due from Relatives & Friends
34
Real Estate Mortgage Payable
15
Other Securities - Not Readily Marketable
35
Liens & Assessments Payable
16
Personal Property
36
Other Debts - Itemize
17
Other Assets - Itemize
37
18
38
TOTAL LIABILITIES
$0.00
19
39 Net Worth (Total Assets - Total Liabilities)
$0.00
20
TOTAL ASSETS
$0.00
40
TOTAL LIABILITIES & NET WORTH
$0.00
ANNUAL INCOME
ESTIMATE OF ANNUAL EXPENSES
Salary, Bonuses & Commissions
Income Taxes
Dividends & Interest
Other Taxes
Rental & Lease Income (Net)
Insurance Premiums
Other Income - Itemize
Mortgage Payments
Other Persons Salary, Bonuses & Commissions
Rent Payable
Other Income of Other Person - Itemize
Other Expenses
Total
$0.00
Total
$0.00
GENERAL INFORMATION
CONTINGENT LIABILITIES
Are any Assets Pledged?
No
Yes
As Endorser, Co-maker or Guarantor- Yes
Are you a Defendant in any Suits or Legal Actions?
No
Yes
On Leases or Contracts
(Explain)
Legal Claims
No
Yes
Federal - State Income Taxes
Have you ever been declared Bankrupt in the last 10 years?
(Explain)
Other -
Section II
A CASH IN BANKS AND NOTES DUE TO BANKS
COLLATERAL (If any)
Name of Bank
Type of Account
Type of Ownership
On Deposit
Notes Due Banks
& Type of Ownership
Cash on Hand
TOTALS
$0.00
$0.00
PERSONAL FINANCIAL STATEMENT
1
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