Millionaire Financial Tracker
Please do not include any identifying numbers like your Social Security number or bank account information. This information for your personal use and Disruptors uses it solely to determine whether the applicant has achieved 100 Millionaire status. We do not share this information with anyone.
Statement is as of
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/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Assets
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Value ($)
Cash (hand & bank)
Savings Accounts
IRA or Other Retirement Account
Accounts & Notes Receiveable
Life Insurance (cash surrender value only)
Stocks and Bonds
Real Estate
Automobile (present value)
Other Personal Properties (total number)
Other Assets (total number)
Salary
Net Investment Income
Real Estate Income
Other Income (total number)
** Income from alimony, child support or separate maintenance income need not be disclosed in "other income".
Net Income
Please Describe Other Income (if any)
Liabilities
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Value ($)
Accounts Payable
Notes Payable to Banks and Other
Installment Account (Auto)
Installment Account (Other)
Loan on Life Insurance
Mortgages on Real Estate
Unpaid Taxes
Other Liabilities
As Endorser or Co-Maker
Legal Claims & Judgements
Provision for Federal Income Tax
Other Special Debt
Total Liabilities
Please Describe Other Liabilities (if any)
Net Worth
I hereby accept that all claimed above are accurate.
*
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