Financial Statement Doc by kgb20889

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									                                    PERSONAL FINANCIAL STATEMENT

Name                                                                 Position or Occupation

Residence Address                                                                                             Phone
                            STREET                          CITY                    STATE          ZIP

Date

                         ASSETS                    In Even Dollars                            LIABILITIES                    In Even Dollars
Cash – (see Schedule A)                                                  Notes Payable to banks – secured
    Checking
    Savings                                                              Notes Payable to banks – unsecured
    Money Market
    CD’s                                                                 Notes Payable to others

Marketable Securities                                                    Accounts Payable
    Stocks
    Bonds                                                                Real Estate Mortgage Payable – (see Schedule D)
Mutual Funds                                                             Loans on Insurance
                                                                         Loans on 401K
IRA’s – (see Schedule A)                                                 Other Debts – itemize

401K – (see Schedule A)                                                  TOTAL LIABILITIES
                                                                         NET WORTH
     Is 401K accessible?   No     Yes Explain                            TOTAL LIABILITIES AND NET WORTH

Non Marketable Securities – (See Schedule C)                                      PERSONAL AND GENERAL INFORMATION
                                                                         Are you a partner or officer in any other venture? No Yes
Real Estate Owned – (See Schedule D)
                                                                         Are any assets pledged?                             No       Yes
Accounts Receivable
                                                                         Are you a defendant in any suits or legal action?
Personal Property
                                                                         Have you ever taken bankruptcy?
Other Assets – itemize                                                      If yes, Explain:




TOTAL ASSETS

ANNUAL INCOME FOR THIS YEAR
Salary, Bonus and Commissions                  $
Dividends                                      $
Real Estate Income                             $
Other Income                                   $




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                                                              SCHEDULE A – CASH
                                                                                                                           Copy of Statement
Account Number                          Name of Institution                 Name on Account               Amount           Attached (Required)
Checking                                                                                                                       Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
Savings                                                                                                                        Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
Money Markets                                                                                                                  Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
CD                                                                                                                             Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
IRA                                                                                                                            Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
401K                                                                                                                           Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                            SCHEDULE B – MARKETABLE SECURITIES
Number of Shares or                                                                                                        Copy of Statement
Bonds                                      Description                       In the Name of            Market Value        Attached (Required)
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No
                                                                                                                               Yes      No

                                        SCHEDULE C – NON MARKETABLE SECURITIES
                                                                                                     Financial Statement       Number of Shares
                       Description of Securities                        Number of Shares Owned           Book Value              Outstanding




                                                SCHEDULE D – REAL ESTATE OWNED
                                                       % of                                Date                       Market        Mortgage
              Description of Property                Ownership   Title in Name of         Acquired      Cost          Value       Amount Payment




THE UNDERSIGNED CERTIFIFIES THAT BOTHSIDES HEREOF AND THE INFORMATION INSERTED THEREIN HAS
BEEN CAREFULLY READ AND IS TRUE, CORRECT AND COMPLETE.

SIGNATURE                                                                                     DATE SIGNED

SIGNATURE                                                                                     DATE SIGNED



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