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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