Personal Financial Statement

Personal Financial Statement as of:*

Individual Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Position or Occupation*

Number of Years at Position or Occupation*

Name of Business*

Address of Business*

Street Address Address Line 2 City State ZIP Code

Residential Phone*

Business Phone*

Email*

Date of Birth*

Other Party Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Position or Occupation*

Number of Years*

Name of Business*

Address*

Street Address Address Line 2 City State ZIP Code

Residential Phone*

Business Phone*

Email*

Date of Birth*

Assets

Current Assets (Readily Convertible to Cash)

Cash and Savings*

Securities Owned*

Marketable

Certificates of Deposit*

Receivables due from others*

Less than 1 year

Cash Value-Life Insurance*

Other Current Assets*

Total Assets*

Non Current Assets

Real Estate Owned*

Investments*

Non-Marketable

Receivables*

1 year or longer

Retirement Funds*

Personal Property*

Vehicles*

Business Ventures*

Other Assets*

Annual Income

Salary, Bonus, and Commissions*

Dividends & Interest*

Rental and Lease Income*

Net

Other Party's Income*

Other Income*

Income from alimony, child support, need not be revealed if you do not choose to rely on it for repayment of this obligation

Total*

Liabilities

Current Liabilities (Due within 12 months)

Notes Payable*

Less than 1 year

Accounts Payable*

eg. Charge cards/accounts

Taxes and Interest Payable*

Total current Liabilities:*

Other current Liabilities:*

Total Current Liabilities*

Non Current Liabilities (Term Debt)

Intermediate Term Liabilities*

eg. Installment Loans

Long Term Liabilities*

eg. Real Estate Loans

Other Liabilities*

Contingent Capital Gains Tax Liability*

Total Liabilities*

Net Worth*

Total Liabilities & Net Worth*

Estimate of Annual Expenditures

Mortgage/Rental payments*

Real estate taxes and assessments*

Taxes*

Federal/State/Local

Insurance Payments*

Other contract payments*

car, charge cards, etc.

Alimony, child support, maintenance*

Other Expenditures*

Total*

SCHEDULE A: Cash and/or Savings

List*

Account Description

Institution Name

In the Name(s) of

Amount

Total*

SCHEDULE B: Securities/Investments Owned (stocks, bonds, mutual funds, etc.)

List*

Number of Shares of Bond Amount

Description

In Name of

Are These Registered, Pledged, or Held by Others?

Present Value

Marketable or Non Marketable

Total Registered, Pledged, or Held By Others*

Total Present Value*

SCHEDULE C: Life Insurance

List*

Insured

Insurance Company

Beneficiary

Face Value of Policy

Cash Value

Loans

Total Cash Value*

Total Loans*

SCHEDULE D: Real Estate Owned

List*

Address and Type of Property

Title in the Name(s) of

Monthly Income

Cost

Year Acquired

Present Market Value

Amount of Insurance

Total Present Market Value*

SCHEDULE E: Retirement Plan Schedule

List*

% Vested

Company Name

Account Number

Manner of Payout (Annuity, Lump Sum, etc.)

Distribution Date

Beneficiary

Amount

SCHEDULE F: Business Ventures

List*

Business Venture in which you are a Principal or Partner

Your Position/Title in Business

Nature of Business

Years in Business

Your % of Ownership

Net Worth of Business

Present Net Value of Your Investment

SCHEDULE G: Mortgages or Liens on Real Estate

List*

Address and Type of Property

To Whom Payable

1st or 2nd Lien

How Payable

Interest Rate

Maturity Date

Unpaid Balance

SCHEDULE H: Loans Payable to Banks & Others and Installment Contracts Payable

List*

To Whom Payable

Address

Collateral or Unsecured

How Payable

Maturity Date

Unpaid Balance

Total Unpaid Balance*

Income Tax Returns Filed Through (Date):*

Are any returns currently being audited or contested? If so, what year?*

If yes, what year?*

In the last 7 years, have you any unsatisfied judgements?*

In the last ten years, have you been declared bankrupt?*

In the last 7 years, have you had property foreclosed upon or given title or deed in lieu thereof?*

Are you a co-maker, guarantor or endorser on a note?*

If yes, denote amount*

Are you a party in a lawsuit?*

Are you obligated to pay alimony, child support or separate maintenance?*

Do you have a will in place?*

Do you have an estate plan in place?*

Name of Attorney*

First Last

Phone Number of Attorney*

Name of Accountant*

First Last

Phone Number of Accountant*

The undersigned acknowledge and understand that the surety is relying on the information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the undersigned represents, warrants and certifies that the information provided herein is true, correct and complete. Unless notified of any change, we will continue to rely upon the statement herein as a true, complete and accurate statement. The undersigned authorize any person or consumer reporting agency to give the surety any information it may have on the undersigned.*