PERSONAL FINANCIAL STATEMENT



PERSONAL FINANCIAL STATEMENT

Answer all Questions, Use additional page if needed.

__________________________ ___________________________________ ________________________

Applicant’s Name: S.S. #: Date:

CURRENT ASSETS

Cash in __________________________ $_____________

Name of Bank

Cash in __________________________ $_____________

Name of Bank

Submit copy of current 3 months personal bank statements

Stocks, Bonds, etc. Market value $ ____________

Submit proof of value

Total $ ____________

Real Estate – Give locations and a copy of your current Tax Assessment(s). You may also include a written appraisal to prove property value. Provide a deed for out of state property.

1._____________________________ $_____________

_____________________________

2. _____________________________ $_____________

_____________________________

Total $_____________

Other Assets – For Vehicles – Copy of Title and printout of Kelly Bluebook value must be provided. Other assets will be considered at the discretion of the Commission.

1._____________________________ $_____________

_____________________________

2. _____________________________ $_____________

_____________________________

Total $_____________

Total Assets $_____________

CURRENT LIABILITIES (From Credit Report)

Creditors

1. To_____________________ Bal. Due $____________

2. To_____________________ Bal. Due $____________

3. To_____________________ Bal. Due $____________

4. To_____________________ Bal. Due $____________

5. To_____________________ Bal. Due $____________

6. To_____________________ Bal. Due $____________

Past Due $ _________________________

Total $_____________

Income taxes (Unpaid Balance)

Federal $________________

State $________________

Total $________________

Open Judgments/ Liens

Date & Description (on separate page)

1. ________________________ $___________________

2. ________________________ $___________________

Total $___________________

Provide name of mortgage holder and Balance due.

1. __________________________ $____________

2. __________________________ $____________

3. __________________________ $____________

Total Mortgages $____________

Other liabilities

1. ________________________ $______________

2. ________________________ $______________

Total Other Liabilities $______________

Total Liabilities $_______________

Net Worth $_______________

(Must be $20,000 or more)

(Assets minus Liabilities = net worth)

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