Personal Financial Statement Please enable JavaScript in your browser to complete this form.PERSONAL FINANCIAL STATEMENT AS OF:Name of IndividualSocial Security NumberDate of BirthName of SpouseSocial Security NumberDate of BirthResidential AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneAssetsCash in Banks Notes Receivable Accounts Receivable Stocks/Bonds/Securities Real Estate (Residence)Real Estate (Investment/Other)Cash Value Life InsurancePersonal PropertyOther AssetsTotal AssetsTotal AssetsLiabilitiesLoans Payable (Banks)Notes PayableAccounts PayableTaxes PayableMortgages PayableOther LiabilitiesTotal LiabilitiesTotal LiabilitiesNet Worthnet worth INCOMESalaryBonus/OtherSpouse’s SalaryBonus/OtherTotal IncomeTotal IncomeSUPPLEMENTARY SCHEDULES OF ASSETS & LIABILITIES(NOTE: All data listed above must appear in the appropriate schedules. Insert “NONE” where appropriate.)CASH IN BANKSBank Name, Branch & LocationAccount NumberAmountBank Name, Branch & LocationAccount NumberAmountBank Name, Branch & LocationAccount NumberAmountNOTES & ACCOUNTS RECEIVABLEName & Address of DebtorAmountDue DatePledgedYesNoSecurityName & Address of DebtorAmountDue DatePledgedYesNoSecurityName & Address of DebtorAmount Due DatePledgedYesNoSecuritySTOCKS/BONDS/SECURITIESName & Number(s) of Stock, Bond or SecurityNo. of SharesPrice/ShareMarket ValueExchange & Call SignName & Number(s) of Stock, Bond or SecurityNo. of SharesPrice/ShareMarket ValueExchange & Call SignName & Number(s) of Stock, Bond or SecurityNo. of SharesPrice/ShareMarket ValueExchange & Call SignREAL ESTATELocation/DescriptionYear AcquiredCostMarket ValueMonthly IncomeMonthly PaymentMortgage BalanceMortgage or Lien holderLocation/DescriptionYear AcquiredCostMarket ValueMonthly IncomeMonthly PaymentMortgage BalanceMortgage or Lien holderLocation/DescriptionYear AcquiredCostMarket ValueMonthly IncomeMonthly PaymentMortgage BalanceMortgage or Lien holderCASH VALUE OF LIFE INSURANCEName of Insurance CompanyBeneficiaryFace ValueCash ValueLoans OutstandingName of Insurance CompanyBeneficiaryFace ValueCash ValueLoans OutstandingName of Insurance CompanyBeneficiaryFace ValueCash ValueLoans OutstandingOTHER ASSETSDescriptionTitle HolderCostMarket ValueAge of AssetDescriptionTitle HolderCostMarket ValueAge of AssetDescriptionTitle HolderCostMarket ValueAge of AssetLOANS PAYABLEName of LenderAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBalance DueAmount Due in One YearHow SecuredName of LenderAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBalance DueAmount Due in One YearHow SecuredName of LenderAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBalance DueAmount Due in One YearHow SecuredACCOUNTS & NOTES PAYABLE (INCLUDING CHARGE ACCOUNTS)Payable to WhomAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAmountMonthly PaymentDue DateHow SecuredPayable to WhomAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAmountMonthly PaymentDue DateHow SecuredPayable to WhomAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAmountMonthly PaymentDue DateHow SecuredTAXES PAYABLE (STATE & FEDERAL)DescriptionAmountDate Payment is DueDescriptionAmountDate Payment is DueDescriptionAmountDate Payment is DueOTHER LIABILITIESDescriptionPayable to WhomAmountMonthly PaymentDue DateHow SecuredDescriptionPayable to WhomAmountMonthly PaymentDue DateHow SecuredDescriptionPayable to WhomAmountMonthly PaymentDue DateHow SecuredAre you contingently liable or an endorser on any bonds or other obligations?YesNoAre you involved in any litigation?YesNoHave you filed for bankruptcy in the last 7 years?YesNoByDateByDateSubmit
