PERSONAL FINANCIAL STATEMENT
NAME
*
First Name
Last Name
AS OF DATE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ASSETS
*
Rows
AMOUNT
Cash, Checking, Savings, Money Market, Time Deposits
Cash Value of Life Insurance
Stocks and Bonds (Publicly traded, listed)
Stocks and Bonds (Not publicly traded, listed)
Accounts and Notes Receivable
Mortgage and Contracts for Deeds Owned
Annuities
Retirement Accounts
Closely-Held Business Interests
Real Estate-Homestead
Real Estate-Other
Real Estate-Time Shares
Oil and Gas
Automobiles
Personal Property
Other Assets
Assets Held Outside the U.S.
TOTAL ASSETS:
LIABILITIES
*
Rows
AMOUNT
Installment Loans Payable to Institutions
Installment Loans Payable to Individuals
Credit Card Debt
Lines of Credit
Income Taxes Payable
Other Taxes Payable
Mortgage on Homestead-1st Lien
Mortgage on Homestead-2nd Lien
Mortgages or Liens on Other Real Estate
Contracts for Deed
Other Liabilities-Partnerships
Other Liabilities-Closely Held Businesses
Other Liabilities
Total Liabilities
Net Worth
INCOME
*
Rows
AMOUNT
Personal Income
Wages, Salary
Pensions and Annuities
Social Security Benefits
Other (Specify) Trust Income
Other (Specify)
Total Personal Income
Business/Real Estate Income
Sales/Rent Revenue
Operating Expenses
Other Income (Specify) Sale of Assets
Other Expenses (Specify) Uninsured Losses
Total Business Income
Total Income
LIST UNUSUAL PERSONAL EXPENSES BELOW
*
Rows
EXPENSE
AMOUNT
1
2
3
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: