National Empowerment Fund | Growing Black Economic ...
PERSONAL STATEMENT OF ASSETS AND LIABILITIES
| |CLIENT | |SPOUSE |
|Name: |Asset |Liability | |Asset |Liability |
|FIXED PROPERTY | | | | | |
|Address |Date |Cost (Include | | | | | |
| |Acquired |Improvements) | | | | | |
|1. | | | | | | | |
|2. | | | | | | | |
|3. | | | | | | | |
| | | | | | |
|INVESTMENTS | | | | | |
|Cash and Bank Balances | | | | | |
|Unit Trusts | | | | | |
|Listed Shares | | | | | |
|Company name |Number | | | | | |
| |of shares | | | | | |
|1. | | | | | | |
|2. | | | | | | |
|3. | | | | | | |
|Unlisted Investments | | | | | |
|(Private companies/CC's/trusts/private practice) | | | | | |
|Entity Name |Percentage | | | | | |
| |interest | | | | | |
|1. | | | | | | |
|2. | | | | | | |
| | | | | | |
|OTHER ASSETS | | | | | |
|Motor Vehicles | | | | | |
|Make and Model |Cost | | | | | |
|1. | | | | | | |
|2. | | | | | | |
|Equipment | | | | | |
|Furniture and fittings | | | | | |
|Debtors | | | | | |
|Other (details) | | | | | |
| | | | | | |
|OTHER LIABILITIES | | | | | |
|Unsecured Borrowings |Bank | | | | | |
|Mortgage: | | | | | | |
|Unsecured Loans: | | | | | | |
|Credit Cards | | | | | | |
|Contingent Liabilities (for example suretyships) | | | | | |
|1. | | | | | |
|2. | | | | | |
|TOTALS | | | | | |
|NET ASSETS (ASSETS - LIABILITIES) | | | | | |
|Signature: | | |Date: | |
PERSONAL STATEMENT OF MONTHLY INCOME AND EXPENDITURE
|Name | |Date | | | | | |
|INCOME | |CLIENT | |SPOUSE |
|Salary | | | | |
|Commission | | | | |
|Other income (rental) | | | | |
| Source of other income | | | | | |
| | | | | | |
|TOTAL | | | | |
|EXPENSES | | |
|Salary deductions ie. tax, pension etc. | | | | |
|Medical Aid (unless a salary deduction) | | | | |
|Bond repayment & Rent | | | | |
|Car Repayment | | | | |
|Loan Repayment | | | | |
| 1. Student Loan | | | | |
| 2. Department Stores | | | | |
| 3. Credit Card | | | | |
| 4. Other | | | | |
|Food | | | | |
|Water, Electricity, Rates & Taxes | | | | |
|Petrol and Vehicle Maintenance | | | | |
|Insurances | | | | |
| 1. Life | | | | |
| 2. Motor Vehicle | | | | |
| 3. Household | | | | |
|Savings eg. Unit trusts | | | | |
|Maintenance/Alimony | | | | |
|Entertainment | | | | |
|Education | | | | |
|Clothing | | | | |
|Other | | | | |
|TOTAL | | | | |
|NET SURPLUS/(DEFICIT) | | | | |
|I warrant that the information contained herein is true and correct. | | |Signature | |
|Dated at | |on | | | |
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