Financial Statement Form

STRICTLY CONFIDENTIAL
GENERAL
Name:
Address:
City:
State:
Zip:
Telephone:
Fax:
Email:
ASSETS
Cash on Hand in Banks:
$
U.S. Government Securities:
$
Accounts, Loans and Notes Receivable:
$
Cash Surrender Value Life Insurance:
$
Value of Business Owned:
$
Other Stocks and Bonds:
$
Real Estate:
$
Automobiles (Quantity):
#
Automobiles (Total Value):
$
Household Furnishings/Personal Effects:
$
Other Assets (Please Itemize):
$
Total Assets:
$
LIABILITIES AND NET WORTH
Notes Payable:
$
Liens on Real Estate:
$
Other Liabilites (Please Itemize):
$
Total Liabilites:
$
Net Worth:
$
SOURCE OF INCOME:
Salary:
$
Dividends and Interest:
$
Bonus and Commissions:
$
Real Estate Income:
$
Other Income:
$
Total Income:
$
The undersigned certifies that this information was provided by him/her and is correct.
Typed Signature:
Date:

 

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