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Personal Financial Statement

Personal Financial Statement
Fields marked with * are required.
* Personal Financial Statement of:		* S.S. NO.:
as of:
* Home Address
* Name of Spouse:		S.S. NO.
* Name of Trusts:		* Trustees

Assets	Amount in Dollars
Cash - checking accounts:	$
Cash - savings accounts:	$
Certificates of deposit:	$
Securities - stocks / bonds / mutual funds:	$
Notes & contracts receivable:	$
Life insurance (cash surrender value):	$
Personal property (autos, jewelry, etc.):	$
Retirement Funds (eg. IRAs, 401k):	$
Real estate (market value):	$
Other assets (specify):	$
Other assets (specify):	$
Total Assets:	$

Liabilities	Amount in Dollars
Current Debt (Credit cards, Accounts):	$
Notes payable (describe below):	$
Taxes payable:	$
Real estate mortgages (describe):	$
Other liabilities (specify):	$
Other liabilities (specify):	$
Total Liabilities:	$
Net Worth:	$

Signature:

Date:

Personal Finance Statement Of:

Details

ASSETS - Details

Notes and Contracts held
From Whom Owing	Balance Owing $	Original Amount $	Original Date	Monthly Payment $	Maturity Date	History / Purpose

Securities: stocks / bonds / mutual funds
Name of Security	Number of Shares	Cost $	Market Value $	Date of Acquisition

Stock in Privately Held Companies
Company Name	No. of shares	$ Invested	Est. Market Value $

Real Estate
Description / Location	Market Value $	Amount Owing $	Original Cost $	Purchase Date

2. LIABILITIES - Details

Credit Card & Charge Card Debt
Name of Card / Creditor	Amount Due $

Notes Payable (excluding monthly bills)
Name of Creditor	Amount Owing $	Original Amount $	Monthly Payment $	Interest Rate %	Secured by (Leine)

Mortgage / Real Estate Loans Payable
Name of Creditor	Amount Owing $	Original Amount $	Monthly Payment $	Interest Rate	Secured by (Leine)


	(Please enter the security code correctly) Click here if you can’t read.

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