Financial Statement

							                                                    FINANCIAL STATEMENT


Dear
          (Legal Representative)




The following is a quarterly/annual financial record for                                             .
If you have any questions concerning this statement, please contact me within ten days. If no contact
is made within the timeframe, it is understood that you agree with the accuracy of these figures.


                                                    Total balance in checking account: $

                                                     Total balance in savings account: $

                                                                      Total cash on hand: $

                                                                          Total Assets:   $

                                                                          Burial Account: $

                                                                          Life Insurance: $

                                                                                  Other: $




Signature and Title of Person Preparing Statement              Date                           Phone No.



Signature of Individual                                        Date




  Revised October 27, 2010                                  Page 1 of 1