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									                                                    CONFIDENTIAL FINANCIAL STATEMENT

Name(s):

Street Address:
City:                                                                                 State:                Zip Code:
Assets
Cash on Hand and in Banks................................................................ $
U.S. Government Securities .................................................................
Accounts, Loans, and Notes Receivable ...............................................
Cash Surrender Value Life Insurance ...................................................
Value of Businesses Owned ..................................................................
Listed Stocks and Bonds ......................................................................
Privately-held Stocks & Bonds ............................................................
House (Market Value) ..........................................................................
Automobile-Number (             ) ...............................................................
Household Furnishings and Personal Effects.........................................
Real Estate (other than House) .............................................................
Other Assets (Itemize) ..........................................................................

                                                            TOTAL ASSETS                               $
Liabilities and Net Worth
Notes Payable .................................................................................... $
Loan on House .....................................................................................
Liens on Real Estate.............................................................................
Credit Card Debt (over 30 days) ..........................................................
Other Liabilities (Itemize) ....................................................................

                                                   TOTAL LIABILITIES                                   $
                                                         NET WORTH                                     $
Source of Income
Salary................................................................................................. $
Dividends and Interest ..........................................................................
Bonus and Commissions .......................................................................
Real Estate Income...............................................................................
Other Income........................................................................................

                                                          TOTAL INCOME                                 $

              The undersigned certifies that he/she provided this information and it is true and correct.
Date:
Signature:                                                                                      Home Phone:
Broker:     AccuBrokers, Inc. - Ron Yurick, CBI
Address:     11535 Park Woods Circle, Suite A
City:    Alpharetta                                                                   State: GA       Zip: 30005
Phone:     770.667.2475          Fax: 770.667.4921                                         email: ryurick@accubrokers.com



 2004, AccuBrokers, Inc., Georgia Association of Business Brokers, Inc.                                    GABB FORM BFS 100, 06/26/2004

								
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