Sample Completed Personal Financial Statement - FINAL#11
Sample Completed Personal Financial Statement
Personal Financial Statement as of: __12/31/XX__________________
Company Name & Address: __________(Your company name here)________________
__First owner_________________________________________________________________________
Name of Individual
Social Security No.
Age
_____________________________________________________________________________________
Spouse's Name
Social Security No.
Age
__Home address________________________________________________________________________
Residence Address
Occupation
Assets
Liabilities
1. Cash on hand and in Banks...................$____50,000_________
1. Accounts Payable...................................$____7,500______
2. Savings Accounts.............................$_____10,000________
2. Notes Payable to Bank/Others...(section 2).....$___10,000______
3. IRA or Other Retirement Accounts..........$_ _140,000_______ 4. Life Insurance ? Cash Surrender Value)...$__________________
3. Installment Account Auto)........................$_____________ Monthly Payment $________
4. Installment Accounts (Other).....................$_____________
5. Stocks and Bonds...(Section 3) .............$_____20,000_______
5. Loan on Life Insurance............................$_____________
6. Real Estate......(Section 4)...................$____125,000________
6. Mortgages on Real Estate...(Section 4).........$___100,000_____
7. Automobile ? Present Value.................$__________________
7. Unpaid Taxes......(Section 6)....................$______________
8. Other Personal Property...Section 5)......$__________________
8. Other Liabilities......(Section7)...................$______________
9. Other Assets...(Section 5)....................$__________________
Total Liabilities...(1-8 above).........................$___117,500_____
Total Assets (1-9 above)..........................$___345,000________
Net Worth......(Total Assets ? Total Liabilities)...$__227,500_____
Total (Net Worth + Liabilities)........................$__345,000_____ (this number should match total assets column)
Section 1. Source of Income
Contingent Liabilities
Salary................................................$___75,000_________
As Endorser or Co-maker...............................$_____________
Net Investment Income............................$__________________
Legal Claims & Judgments.............................$______________
Real Estate Income.................................$___10,000_________
Provisions for Income Taxes...........................$_____________
Other Income (describe below)....................$_________________
Other Special Debt ......................................$______________
Description of Other Income in Section 1.______________________________________________________________________________________
________________________________________________________________________________________________________________________
Section 2. Notes Payable to Banks and Others Name and Address of Noteholder Bank of _______, (address)
Original Balance
50,000
Current Balance
10,000
Payment Amount
$1,000
Frequency Monthly
How Secured or Type of Collateral Not secured
Section 3. Stocks and Bonds Name of Security/Exchange Listed New York Stock Exchange ? Any Stock XXX
Number of Shares
1000
Cost 5,000
Market Value Quote 20 per share
Date of Quote
7/1/20XX
Total Value of Security
20,000
Section 4. Real Estate Owned Type of Property (Residential/Commercial) Address
Date Purchased
Original Cost
Present Market Value
Name/Address of Mortgage Holder Mortgage Account Number
Mortgage Balance
Monthly Payment Status of Mortgage
Property A
Commercial XX Main St., Any town, Any state
5/1/19XX
Property B Residential
XXX Any street, Any Town, Any State 6/5/20XX
25,000
45,000
25,000
100,000
No mortgage on property
XXX Bank, Any Street, Any Town
0
100,000
0
$565
n/a
current
Property C
Section 5. Other Personal Property and Other Assets. Section 6. Unpaid Taxes. Section 7. Other Liabilities.
Section 8. Life Insurance Held. Give Face Amount and cash surrender values of policies ? name of insurance company and beneficiaries.
____________________________________________________________
Signature
Date
____________________________________________________________
Signature
Date
_______________________________________ Social Security Number
_______________________________________ Social Security Number
................
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