${input_2_16}

PERSONAL FINANCIAL STATEMENT

Prepared for ${input_2_26}

on ${input_2_19}

NAME:

${input_2_26}

ADDRESS:

${input_2_32_1}

 

${input_2_32_3} , ${input_2_32_4}

${input_2_32_5}

HOME PHONE:

${input_2_33}

CELL PHONE:

${input_2_34}

SSN:

BIRTHDATE:

${input_2_38}

DETAILED SUMMARY LISTING OF ASSETS

INDIVIDUAL ASSET INFORMATION

AMOUNT

Accounts Receivable:

Annuity:

Boats:

Bonds:

Business Property and Real Estate:

Certificate of Deposit:

Checking Accounts:

Household Furnishings:

Jewelry:

Life Insurance:

Mutual Funds:

Notes Receivable:

Other Assets:

Other Real Estate:

Personal Residence Real Estate:

Recreational Equipment:

Retirement Plans:

Savings Accounts:

Stocks:

Trusts:

Vehicles:

INDIVIDUAL TOTAL ASSET VALUE:

$0.00

DETAILED SUMMARY LISTING OF LIABILITIES

INDIVIDUAL LIABILITY INFORMATION

AMOUNT

Mortgage or Rent:

Home Equity Loan:

Other Mortgage:

Vehicle Loans:

Credit Cards:

Student Loans:

Other Liabilities:

INDIVIDUAL TOTAL LIABILITIES:

$0.00

DETAILED SUMMARY LIST OF MONTHLY INCOME ASSET

INDIVIDUAL MONTHLY INCOME

MONTHLY AMOUNT

Monthly Salary or Wages:

Investment Accounts:

Alimony:

Child Support:

Trusts:

Other Income Sources:

INDIVIDUAL TOTAL MONTHLY INCOME ASSET:

$0.00

DETAILED SUMMARY LIST OF MONTHLY EXPENSE LIABILITY

INDIVIDUAL MONTHLY EXPENSES

MONTHLY AMOUNT

Paid Alimony:

Paid Child Care:

Groceries:

Healthcare or Medications:

Housing or Rent:

Other Mortgage Loans:

Auto Loans:

Auto Insurance:

Health or Dental Insurance:

Life Insurance:

Other Insurance:

Credit Cards:

Student Loans:

Other Expenses:

INDIVIDUAL TOTAL MONTHLY EXPENSE LIABILITY:

$0.00



NET WORTH SUMMARY

TOTAL ASSETS:

$0.00

TOTAL LIABILITIES:

$0.00

TOTAL NET WORTH:

$0.00

I , ${input_2_81} , hereby certify and warrant, to the best of my knowledge, that the aforementioned information contained within this Personal Financial Statement is true, accurate and complete.

DATE : ${input_2_19}

${input_2_81}