Personal Financial Statement

PERSONAL FINANCIAL STATEMENT

I. IDENTIFICATION

Name:

Date of Birth:    Phone:

Single    Married    Separated    Domestic Partner

II. EMPLOYMENT / BUSINESS INFORMATION

Position/Title:    Years Employed:    Ownership Interest (%):

III. STATEMENT OF ASSETS

Cash on Hand: $

Retirement Accounts (total market value): $

REAL ESTATE & PERSONAL PROPERTY

Mortgage Balance on Property 1: $

Mortgage Balance on Property 2: $

IV. STATEMENT OF LIABILITIES

Automobile Loans (total outstanding): $    Student Loans (total outstanding): $

Total Assets: $    Total Liabilities: $    Net Worth: $

V. INCOME & MONTHLY EXPENSES

Base Salary (annual): $    Bonus / Commissions (annual): $

Total Monthly Income: $    Total Monthly Expenses: $

VI. CONTINGENT LIABILITIES & LEGAL MATTERS

VII. ADDITIONAL INFORMATION

VIII. CERTIFICATION AND AUTHORIZATION

I certify that the information contained in this Personal Financial Statement is true, complete and correct to the best of my knowledge and belief. I understand that this Statement may be relied upon by lenders, holders, or potential creditors in evaluating my creditworthiness. I authorize those parties to verify any information provided herein and to obtain reports or other information necessary to confirm my financial condition. I agree to promptly notify the requesting party of any material change in my financial condition and to provide updated statements upon request.

I acknowledge that any material misstatement or omission may constitute a fraudulent act and may subject me to civil and criminal penalties under applicable law. I consent to the release of information contained in this Statement to credit reporting agencies and to any third party with a legitimate need to verify information for credit, underwriting, or collection purposes.

Authorization to Contact Financial Institutions: I authorize the verification of accounts and balances with financial institutions listed herein.

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