PERSONAL FINANCIAL STATEMENT
Section 1(a) - Personal Information
Name: Joe T. Example Address: Any Street Employer: Any Employer Employer's Address: Any Employer's address Business Phone: 333-444-5555 City: Any City Position: Any position City: Any Employer's city Residence Phone: 222-333-4444 State: TX Date: 06/25/04 Birthdate: 05/05/55 SS# 123-45-6789 State: TX Zip: 11111 # of Years: 10 Zip: 45678
Drivers License #: 123456789
Section 1(b) - Other Party Information
Name: Jane T. Example Address: Any Street Employer: Any Employer # 2 Employer's Address: Any Employer's address Business Phone: 111-222-3333 City: Any City Position: Any position City: Any Employer # 2 Address Residence Phone: 222-333-4444 State: TX Birthdate: 06/06/56 SS# 333-44-6666 State: TX Zip: 11111 # of Years: 10 Zip: 32145
Drivers License #: 9874565
Section 2 - Statement of Financial Condition Assets
Cash: (Refer to Schedule A) Securities: (Refer to Schedule B) Real Estate: (Refer to Schedule C) Automobiles: Restricted or Margin Accounts: Cash Value Life Insurance: Accounts and Notes Receivable: Household & Personal Assets: All Other Assets: Total Assets:
In Dollars
Liabilities
In Dollars
$45,000.00 $50,000.00 $3,500.00
$15,000.00 Notes Payable: (Refer to Schedule D) $1,500.00 $150,000.00 $38,000.00 $0.00 $0.00 $0.00 $0.00 Total Liabilities: $0.00 Net Worth: (Total Assets - Total Liabilities) $204,500.00 Total Liabilities & Net Worth: Mortgages Payable: (Refer to Schedule C) All Other Liabilities:
$98,500.00 $106,000.00 $204,500.00
Section 3 - Annual Income
Federal Income Tax Information for the Year Ended 2003 Salaries & Wages (Individual): Salaries & Wages (Spouse): Bonuses & Commissions: Dividends & Interest Income: Net Real Estate Income: Oil & Gas Income/Royalties: All Other Income:
Annual Expenditures
$75,000.00 Installment Payments (auto, credit cards) $75,000.00 Lease Obligations: $0.00 Mortgage/Rental Payments: $0.00 Other Debt Service: $0.00 Alimony, Child Support, etc: $0.00 Auto, Life & Health Insurance Premiums: $0.00 All Other Expenditures: $10,200.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Total Income:
$150,000.00
Total Expenditures:
$10,200.00
PERSONAL FINANCIAL STATEMENT
Personal Information
Name: Joe T. Example Address: Any Street Business Phone: 333-444-5555 City: Any City Residence Phone: 222-333-4444 Date: 06/25/04 State: TX Zip: 11111
Section 4 General Information
Do you have any contingent liabilities? Yes
X No
Do You have a will?
X Yes
No
As endorser or co maker:
NA
Are you presently involved in divorce proceedings?
Yes
X No
As guarantor:
NA
Have you ever taken bankruptcy? Are you a partner or officer in any other venture? Explanation: NA Are you a defendant in any suit or legal action? Explanation: NA Have you any judgements against you? Explanation: NA
Yes Yes
X No X No
On leases or contracts:
NA
Involvement in pending legal action judgements, or contested tax liens:
NA
Yes
X No
Other special debts or circumstances:
NA Yes
X No
Total Contingent Liabilities
NA
The information contained in this statement and supporting schedules is provided to induce you to extend or to continue the extension of credit to the undersigned or to others upon the guaranty of the undersigned. The undersigned acknowledges and understands that you are relying upon the information provided herein in deciding to grant or continue credit or to accept a guaranty thereof. The undersigned represents, warrants and certifies that the information provided herein is true, correct and complete to the best of the undersigned's knowledge. The undersigned agrees to notify you immediately and in writing of any changes in name, address, or employment and of any material adverse change (1) in any of the information contained in thsi statement or (2) in the financial condition of the undersigned or (3) in the ability of the undersigned to perform its obligations to you. In the absence of such notice or a new and full written statement, this should be considered as a continuing statement and substantially correct. You are authorized to make all inquiries you deem necessary to verify the accuracy of the information contained herein, and to determine the credit worthiness of the undersigned. The undersigned authorizes you to answer questions about your credit experience with the undersigned.
Signed (Individual)___________________________________________________
Date ______________________
Signed (Other Party)_________________________________________________
(I have read and I understand the above paragraph.)
Date ______________________
Disclaimer:
The data and information contained in this document is provided for informational purposes only. Interactive Software Solutions, LP shall not be liable for any errors in content or for any actions taken in reliance theron. Interactive Software Solutions, LP shall not be liable for any damages or costs of any type arising out of or in any way connected with the use of this software.
Financial Statement Details
Name: Joe T. Example Schedule A - Deposit Relationships
Type of Account Savings Account Registered in Name of Joe & Jane Example Bank Your Bank Account Number 11111111 Current Balance $15,000.00
Date: 06/25/04
Total Schedule B - Securities
# Shares 100 Security Any Stock Exchange NASDAQ Pledged No Purchase Price $1,000.00
$15,000.00
Current Value $1,500.00
Total Schedule C - Real Estate & Related Notes Payable
Type Description Year Acquired 1990 % Owned 100 Market Value Lien Holder Current Balance $50,000.00 Monthly Income $0.00
$1,500.00
Monthly Payment $1,275.00
Homestead Joe & Jane's Home
$150,000.00 Any Bank
Total Schedule D - Notes Payable other than Real Estate
Type Auto Debt Creditor Any Auto creditor Date of Loan 12/01/03 Maturity 01/01/08 Collateral Mercedez Current Balance $45,000.00
$150,000.00
Payment Frequency Monthly
Total Section 2 - Statement of Financial Condition Other Assets (Not Listed on Schedules A, B, or C)
Type Automobile Description Mercedez
$45,000.00
Value $38,000.00
Total Other Liabilities (Not Listed on Schedules C or D)
Description Hospital
$38,000.00
Amount $3,500.00
Total Section 3 - Annual Income Detailed Summary
Type Salaries and Wages (Individual) Salaries and Wages (Spouse) Description Joe Examples Income Jane Examples Income
$3,500.00
Amount $75,000.00 $75,000.00
Total Annual Expenditures Detailed Summary
Type Installment Payment (Auto, Credit Card, etc.) Description Mercedez
$150,000.00
Amount $10,200.00
Total
$10,200.00