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      Personal Financial Statement:          
         
         
         
         
       
       
         
      Financial information as of:  
       
         
         
         
      Assets     Amount in Dollars  
    Cash - checking accounts
    Cash - savings accounts
    Certificates of deposit
    Securities - stocks / bonds / mutual funds
    Notes & contracts receivable
    Life insurance (cash surrender value)
    Personal property (autos, jewelry, etc.)
    Retirement Funds (IRAs, 401k, etc.)
    Real estate (market value)
    Stock in privately held companies
    Other assets (specify)
    Total Assets
      Liabilities     Amount in Dollars  
    Current Debt (Credit cards, Accounts)
    Notes payable (describe below)
    Taxes payable
    Real estate mortgages (describe)
    Other liabilities (specify)
    Other liabilities (specify)
    Total Liabilities
      Net Worth      
      Signature:_________________________________ Date:___________  
      Personal Financial Statement of:  
       
    Details
    1. ASSETS - Details
    Securities: Stocks, Bonds, Mutual funds
      Name of Security Number of Shares Cost Market Value Date of Acquisition    
    Notes and Contracts Receivable
      Borrower's Name Balance Due Original Amount Original Date Monthly Payment Maturity Date    
    Real Estate
      Description / Location Market Value Amount Owing Original Cost Purchase Date    
    Stock in Privately Held Companies
      Company Name % Owned $ Invested
    Est. Market Value
     
    2. LIABILITIES - Details
    Current Debt (Credit Cards, Lines of Credit)
    Name of Card / Creditor Amount Owed
    Notes Payable (excluding monthly bills)
      Name of Creditor Amount Owed Original Amount Monthly Payment Interest Rate Secured by (Lien)  
    Mortgage and Real Estate Loans Payable
      Name of Creditor Amount Owed Original Amount Monthly Payment Interest Rate Secured by (Lien)