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 Assets

Cash on Hand and in Banks

$

Stocks, Bonds & Mutual Funds (Current Market Value)

$

Certificates of Deposit

$

Money Market Funds

$

Accounts, Loans and Notes Receivable

$

Cash Value of Life Insurance

$

Value of Businesses owned

$

Real Estate Owned (Current Market Value)

$ 

Automobiles- Number [ ] (Current Market Value)

$

Retirement Account Value (IRA, 401K, Etc)

$ 

Household Furnishings and Personal Effects

$

Other Assets (Itemize below)

$

                                                                                    Total Assets

$

 

                                

 Liabilities

Credit Card Debt

$

Other Credit Debt (Stores, Gas Stations, Etc)

$

Home Mortgage

$

Home Equity Loans

$

Other Mortgages

$ 

Auto Loans

$

Other Loans Outstanding (Itemize below)

$ 

Personal Guarantees of others debts (Itemize below)

$ 

Other Liabilities (Itemize below)

$

                                                                               Total Liabilities

$

 

                            

Net Worth

Total Assets less Total Liabilities                             Net Worth  

$

 

                            

Source of Income

Annual Salary or Wages

$

Dividends and Interest

$

Bonus and Commissions

$

Real Estate Income

$

Other Income (Itemize below)

$

 Annual Income                                                       Total

$

 

                            

Itemize Details

Other Assets:     

Other Liabilities:

Other

Income:

            The individuals below certify this information to be a true

and correct record of their finances.
Name(s):  &        

 

Street Address     

 

City:      State:      Zip Code:       

 

Date:      Phone:      Email:     

 

 


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