Date
/
Month
/
Day
Year
Date
Primary Person Full Name
Primary Person Address
City, State, Zip
Phone
Spouse Full Name
Spouse Address
City, State, Zip
Phone
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Assets
Cash on Hand & In Banks
Life Insurance (cash surrender value)
Certificates of Deposits
Securities (stocks, bonds, mutual funds)
Notes & Accounts Receivable
Personal Property (autos, jewelry, etc.)
Retirement Funds (IRAs, 401k)
Real Estate (market value)
Other Assets (specify below)
Total Assets
Liabilities
Current Debt (credit cards, accounts, etc.)
Notes Payable (describe below)
Taxes Payable
Real Estate Mortgages (describe below)
Other Liabilities (specify below)
Total Liabilities
Net Worth (Assets - Liabilities)
Total Liabilities + Net Worth
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Annual Income
Salary, Bonuses & Commissions
Other Income (specify below)
Spouse - Salary, Bonuses & Commissions
Spouse - Other Income (specify below)
Dividends & Interest
Rental & Lease Income (Net)
Total Income
Annual Expenses
Current Debt Payments
Tax Payments
Mortgage/Rent Payments
Note Payments
Other Liabilities Payments
Other Expenses Payments
Total Annual Expenses
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Section II
Cash Details
List Bank Balance Details For All Bank And Cash Accounts
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Bank Name
Type of Account
Amount
Description
Total Amount For All Banks
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Life Insurance
Include All Life Insurance Policies For Primary And Spouse
Life Insurance Type
Life Insurance Company
Description
Active Policy Loans
Face Value of Policy
Cash Surrender Value
Life Insurance Type
Life Insurance Company
Description
Active Policy Loans
Face Value of Policy
Cash Surrender Value
Life Insurance Type
Life Insurance Company
Description
Active Policy Loans
Face Value of Policy
Cash Surrender Value
Total Cash Surrender Value For All Policies
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Securities Owned
List All Securities Owned Including Stocks, Bonds, Mutual Funds, Etc.
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Security Type
Brokerage
Description
Quantity
Original Cost
Market Value
Total Market Value of All Securities
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Notes & Accounts Receivable
Include Details For All Debts Owed To You
Debtor
Original Amount
Monthly Payments
Interest Rate
Maturity
Balance Due
Debtor
Original Amount
Monthly Payments
Interest Rate
Maturity
Balance Due
Debtor
Original Amount
Monthly Payments
Interest Rate
Maturity
Balance Due
Debtor
Original Amount
Monthly Payments
Interest Rate
Maturity
Balance Due
Total Balance Due For All Notes and Accounts Receivable
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Real Estate Owned
List The Details For The Real Estate Owned By You
Property Address
Bank
Monthly Payment
Original Cost
Remaining Balance
Market Value
Property Address
Bank
Monthly Payment
Original Cost
Remaining Balance
Market Value
Property Address
Bank
Monthly Payment
Original Cost
Remaining Balance
Market Value
Total Monthly Payments
Total for All Original Costs
Total for All Remaining Balances
Total for All Market Values
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Mortgages and Contracts Owned
List The Details Of Any Mortgages Or Contracts Owned By You, Including Loans Provided By You To Secure Real Estate
Mortgage/Contract
Collateral
Description
Amount
Mortgage/Contract
Collateral
Description
Amount
Mortgage/Contract
Collateral
Description
Amount
Total for All Mortgage/Contracts Owned
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Personal Property
List All Personal Property Owned Such As Automobiles, Jewelry, Etc.
Named Property
Quantity
Description
Amount
Named Property
Quantity
Description
Amount
Named Property
Quantity
Description
Amount
Named Property
Quantity
Description
Amount
Named Property
Quantity
Description
Amount
Named Property
Quantity
Description
Amount
Total for All Personal Property
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Other Income
Specify All Other Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Company
Primary/Spouse
Description
Annual Income
Total Annual Income for All Other Income
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Other Assets
Specify All Other Assets
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Named Asset
Original Cost
Description
Market Value
Total Market Value of All Other Assets
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Other Liabilities
Specify All Other Liabilities
Named Liability
Original Amount
Description
Remaining Balance
Named Liability
Original Amount
Description
Remaining Balance
Named Liability
Original Amount
Description
Remaining Balance
Named Liability
Original Amount
Description
Remaining Balance
Named Liability
Original Amount
Description
Remaining Balance
Total Remaining Balance for All Other Liabilities
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Notes
List Details Of All Notes That You Owe To A Lender
Bank
Original Amount
Description
Remaining Balance
Bank
Original Amount
Description
Remaining Balance
Bank
Original Amount
Description
Remaining Balance
Bank
Original Amount
Description
Remaining Balance
Bank
Original Amount
Description
Remaining Balance
Total Remaining Balance For All Notes
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Primary Person Signature
Spouse Signature
Date
-
Month
-
Day
Year
Date
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