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Personal Financial Statement

PERSONAL FINANCIAL STATEMENT AS OF:

Name of Individual

Social Security Number

Date of Birth

Name of Spouse

Social Security Number

Date of Birth

Residential Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Assets

Cash in Banks

Notes Receivable

Accounts Receivable

Stocks/Bonds/Securities

Real Estate (Residence)

Real Estate (Investment/Other)

Cash Value Life Insurance

Personal Property

Other Assets

Total Assets

Liabilities

Loans Payable (Banks)

Notes Payable

Accounts Payable

Taxes Payable

Mortgages Payable

Other Liabilities

Total Liabilities

Net Worth

net worth

INCOME

Salary

Bonus/Other

Spouse’s Salary

Bonus/Other

Total Income

SUPPLEMENTARY SCHEDULES OF ASSETS & LIABILITIES

(NOTE: All data listed above must appear in the appropriate schedules. Insert “NONE” where appropriate.)

CASH IN BANKS

Bank Name, Branch & Location

Account Number

Amount

Bank Name, Branch & Location

Account Number

Amount

Bank Name, Branch & Location

Account Number

Amount

NOTES & ACCOUNTS RECEIVABLE

Name & Address of Debtor

Amount

Due Date

Pledged

Yes
No

Security

Name & Address of Debtor

Amount

Due Date

Pledged

Yes
No

Security

Name & Address of Debtor

Amount

Due Date

Pledged

Yes
No

Security

STOCKS/BONDS/SECURITIES

Name & Number(s) of Stock, Bond or Security

No. of Shares

Price/Share

Market Value

Exchange & Call Sign

Name & Number(s) of Stock, Bond or Security

No. of Shares

Price/Share

Market Value

Exchange & Call Sign

Name & Number(s) of Stock, Bond or Security

No. of Shares

Price/Share

Market Value

Exchange & Call Sign

REAL ESTATE

Location/Description

Year Acquired

Cost

Market Value

Monthly Income

Monthly Payment

Mortgage Balance

Mortgage or Lien holder

Location/Description

Year Acquired

Cost

Market Value

Monthly Income

Monthly Payment

Mortgage Balance

Mortgage or Lien holder

Location/Description

Year Acquired

Cost

Market Value

Monthly Income

Monthly Payment

Mortgage Balance

Mortgage or Lien holder

CASH VALUE OF LIFE INSURANCE

Name of Insurance Company

Beneficiary

Face Value

Cash Value

Loans Outstanding

Name of Insurance Company

Beneficiary

Face Value

Cash Value

Loans Outstanding

Name of Insurance Company

Beneficiary

Face Value

Cash Value

Loans Outstanding

OTHER ASSETS

Description

Title Holder

Cost

Market Value

Age of Asset

Description

Title Holder

Cost

Market Value

Age of Asset

Description

Title Holder

Cost

Market Value

Age of Asset

LOANS PAYABLE

Name of Lender

Address

Address Line 1

City

State

Zip Code

Balance Due

Amount Due in One Year

How Secured

Name of Lender

Address

Address Line 1

City

State

Zip Code

Balance Due

Amount Due in One Year

How Secured

Name of Lender

Address

Address Line 1

City

State

Zip Code

Balance Due

Amount Due in One Year

How Secured

ACCOUNTS & NOTES PAYABLE (INCLUDING CHARGE ACCOUNTS)

Payable to Whom

Address

Address Line 1

City

State

Zip Code

Amount

Monthly Payment

Due Date

How Secured

Payable to Whom

Address

Address Line 1

City

State

Zip Code

Amount

Monthly Payment

Due Date

How Secured

Payable to Whom

Address

Address Line 1

City

State

Zip Code

Amount

Monthly Payment

Due Date

How Secured

TAXES PAYABLE (STATE & FEDERAL)

Description

Amount

Date Payment is Due

Description

Amount

Date Payment is Due

Description

Amount

Date Payment is Due

OTHER LIABILITIES

Description

Payable to Whom

Amount

Monthly Payment

Due Date

How Secured

Description

Payable to Whom

Amount

Monthly Payment

Due Date

How Secured

Description

Payable to Whom

Amount

Monthly Payment

Due Date

How Secured

Are you contingently liable or an endorser on any bonds or other obligations?

Yes
No

Are you involved in any litigation?

Yes
No

Have you filed for bankruptcy in the last 7 years?

Yes
No

By

Date

By

Date

5550 Franklin Pike, Suite 202

Nashville, TN 37220

877-992-6637

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