Personal Financial Statement

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Contact & General Information
Name:
Street Address:
City:
State & Zip Code:
Home Phone Number:
 
  
  
Business Name:
Employer:
Employer's Address:
Position/Profession:
Length of Time in Present Position:
Sources of Income
Even Dollars
Salary
Commissions and Bonus
Interest and Dividends
Real Estate Income
Other Income: Itemized  
Total Income 
Are you relying on your own income & assets for application?
If yes, list only income, assets, and liabilities that apply to you.
Have you ever
filed for bankruptcy?
Are you relying on the income & assets of another for application?
If yes, list income, assets, & liabilities of both you and your spouse
or another person.
ASSETS (Do not fill in, totals will automatically be entered from below)
 
 Total % of Total
Checking and Savings Accounts
Securities: Stocks, Mutual Funds (Market Value)
Bonds (Market Value)
Retirement Accts. (401k, IRA's) (Market Value)
Other Investments (Market Value)
Real Estate (Market Value)
Vehicle, Boats, Planes, Etc. (Market Value)
Personal & Home Assets (Market Value)
Other Assets (Market Value)
Total 
LIABILITIES (Do not fill in, totals will automatically be entered from below)
  Total % of Total
Real Estate Loans/Mortgages Payable
Vehicle, Boats, Planes, Etc. Loans Payable
Credit Card Debt Payable
Loans Payable On Personal/Home Assets
Loans Payable To Banks Or Credit Unions
Other Liabilities Or Debts Payable
Unpaid Taxes Or Liens Payable
Total 
Net Worth
   
ASSETS
   
Checking and Savings Accounts
Type of Account Name on Account Address of Institution Date Account Opened Current Balance
Total 
   
Securities: Stocks, Mutual Funds (Market Value)
(Type and Name of Stock, etc.) Number of Shares Purchase Date Cost Current Market Val.
Total 
Bonds (Market Value)
(Type and Name of Bond) Purchase Date Cost Current Market Val.
Total 
Retirement Accts. (401k, IRA's) (Market Value)
(Type and Name of Fund) Current Market Val.
Total 
   
Other Investments (Market Value)
(Type of Investment) Shares or %Ownership Miscellaneous Description, If Needed Cost Current Market Val.
Total 
Real Estate (Market Value)
Describe Type of Property Purchase Date Original Cost Current Bal. Owing Current Market Val.
Total 
Vehicle, Boats, Planes, Etc. (Market Value)
Description Purchase Date Original Cost Current Bal. Owing Current Market Val.
Total 
Personal & Home Assets (Market Value)
Description Purch. Date
(if known)		 Original Cost Current Bal. Owing Current Market Val.
Total 
Other Assets (Market Value)
Description Current Bal. Owing Current Market Val.
Total 
   
LIABILITIES
Real Estate Loans/Mortgages Payable
Name of Loan or Mortgage Holder Behind on Payments? Interest Rate Monthly Pymt. Amt. Current Bal. Owing
Total 
Vehicle, Boats, Planes, Etc. Loans Payable
Description Behind on Payments? Interest Rate Current Market Val. Current Bal. Owing
Total 
Credit Card Debt Payable
Type of Credit Card Behind on Payments? Interest Rate Monthly Pymt. Amt. Current Bal. Owing
Total 
Loans Payable On Personal/Home Assets
Description Purch. Date
(if known)		 Original Cost Current Market Val. Current Bal. Owing
Total 
Loans Payable To Banks Or Credit Unions
Name of Bank or Credit Union Interest Rate Payment Amount Original Balance Current Bal. Owing
Total 
Other Liabilities or Debts Payable
Name of Individual or Creditor Interest Rate Payment Amount Original Balance Current Bal. Owing
Total 
Unpaid Taxes or Liens Payable
To Whom Payable Type of Tax or Lien Against What Property Date Due Current Balance Owing
Total 
   
Contingent Liabilities
Are you the co-signer on any loans or agreements? Are you involved in any lawsuits or legal action? Other contingent liabilities
   
I/we have carefully read and submitted the foregoing information provided on all the pages of this statement. The information is presented as a true and accurate statement of my/our financial condition on the date indicated. I/we agree that if any material change(s) occur(s) in my/our financial condition that I/we will immediately notify you of said change(s), and unless so notified it may continue to rely upon this financial statement and the representations made herein as a true and accurate statement of my/our financial condition.
   
I/we give authorization to make whatever credit inquiries necessary to verify the information contained in this financial statement.
   
Applicant's Signature Date Signed Social Security No. Date of Birth
   
Co Applicant's Signature Date Signed Social Security No. Date of Birth
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