Personal Financial Statement

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					11345 SW Megan Terrace                                                     Phone: 503-475-0306
Tigard, OR 97223                                                             Fax: 503-746-7425


                            Personal Financial Statement
                               * Strictly Confidential *


Name                                          Phone                      Cell
Street Address
City                                                         State                Zip

Assets
Cash on hand in banks                                                $
Marketable securities
Accounts, loans, and note receivable
Residence real estate value
Other real estate value
Value of business owned
Vehicles
Household furnishings and personal effects
Other assets (itemize)

                                             Total Assets        $

Liabilities
Notes payable                                                    $
Credit cards payable
Residence real estate mortgages
Other liabilities (itemize)

                                        Total Liabilities        $
                      Net Worth (Assets minus liabilities)       $

Sources of Income
Salary                                                           $
Dividends and interest
Bonus and commissions
Real estate income
Other income

                                             Total Income        $

The undersigned certifies this financial information is provided by them personally and is
true and correct.

Signature                                                        Date

				
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