Personal Financial Statement

Complete this form for each applicant. List only those assets you want to be considered in this personal financial statement.
  • Assets

    Omit cents
  • Liabilities

    Omit cents
  • Section 1. Source of Income

  • Contingent Liabilities

  • Note: Alimony or child support payments do not need to be disclosed in "Other Income" unless it is desired to have such payments counted toward total income

  • Section 2. Loans payable to banks and others

    Lists loans, mortgage, credit card accounts, and indebtedness. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
  • Name and address of noteholder(s)Original balanceCurrent balancePayment amountFrequency (monthly, etc.)How secured or endorsed type of collateral or applicable 
    Add a row
  • Section 3. Stocks and Bonds

    Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.
  • Number of sharesName of securitiesCostMarket value quotation/exchangeDate of quotation/exchangeTotal value 
    Add a row
  • Section 4. Real estate owned

    List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed.
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Property AProperty BProperty C 
    Add a row
  • Section 5. Other personal property and other assets

    Describe, and if any is pledged as security, state, name, and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency
  • Section 6. Unpaid taxes

    Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches
  • Section 7. Other liabilities

    Describe in detail
  • Section 8. Life insurance held

    Give face amount and cash surrender value of policies - and name of insurance company
  • I hereby affirm that this personal financial statement contains no willful misrepresentation or falsifications and this information given by me/us is true and complete to the best of my/our knowledge and belief

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