Personal Financial Statement template.xlsx

	A	B	C	D	E
1	Confidential Personal Financial Statement
2
3	As of date:____6/20/2020__________
4
5	Individual 1 (First, Middle, Last-please print)
6	Carlos Juarez
7	Street Address			Phone
8
9	City/State/Zip			Years at Address
10
11	Date of Birth	SSN		# Dependents
12
13	Employer		Occupation
14
15	Business Address			Years Employed
16
17	City/State/Zip			Business Phone
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19
20
21	ASSETS	Schedules	Solely Owned		Total
22	ASSETS	Schedules	Individual 1 Amount	Individual 2 Amount	Total
23	Cash in Financial Institutions (including money market accounts, CDs)	A	0		0
24	Readily Marketable Securities	B	0		0
25	Non-Readily Marketable Securities (current market value)	C	0		0
26	Cash Surrender Value of Life Insurance (current market value)	D	0		0
27	Residential Real Estate (market value)	E	0		0
28	Real Estate Investments (market value)	F	0		0
29	Real Estate Partnerships	G	0		0
30	Accounts and Notes Receivable	H	0		0
31	IRA, Keogh, Profit-Sharing & Other Vested Retirement Accts	I	0		0
32	Deferred Income	None			0
33	Personal Property and Other Assets(including automobiles)	J	0		0
34	Total Assets		0		0
35
36	LIABILITIES AND NET WORTH	Schedules	Solely Owned		Total
37	LIABILITIES AND NET WORTH	Schedules	Individual 1 Amount	Individual 2 Amount	Total
38	Notes Payable	K			0
39	Accounts Payable (including credit cards)	L			0
40	Margin Accounts	C	0		0
41	Taxes Payable	None			0
42	Mortgage Debt	E	0		0
43	Life Insurance Loans	D	0		0
44	Real Estate Investment Loans	F	0		0
45	Other Liabilities (List) Student Loans	None
46	Total Liabilities		0		0
47	NET WORTH (Total Assets Less Total Liabilities)		0		0
48	Schedule M - Contingent Liabilities
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50
51
52
53
54	Sources of Income (Annual)		Monthly Expenditures
55	Year ending: 2	Individual 1	Year ending:		Individual 1
56	Salary		Mortgage/Rent Residence(s)
57	Bonus and Commissions		All Other Debt Service		0
58	Dividends/Interest		State and Federal Income Tax		0
59	Real Estate Income		Insurance		0
60	Real Estate Partnership		Alimony/Child Support		0
61	Business Income		Other
62	Alimony/Child Support*		Other
63	Other Income		Other
64	Total	0		Total	$0
65
66
67
68	Information Requested:	Individual 1		Comments
69	Information Requested:	Yes	No	Comments
70	Do you have a will?	o	x	Executor:
71	Are you a defendant in any suits or legal action?	o	X	Please describe:
72	Have you filed a petition in bankruptcy or has one been filed against you	o	X	Please describe:
73	Are you an Executive Officer, Director, or Principal Shareholder of a Bank?	o	x	Bank Name:
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75
76
77	SCHEDULE A – CASH HELD IN FINANCIAL INSTITUTIONS
78	Account Number	Type of Account	Financial Institution Name		Balance
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80
81
82
83
84
85
86				Total	0
87
88
89	SCHEDULE B – READILY MARKETABLE SECURITIES (including non-money market mutual funds)
90	# shares (stock) or face value (bonds)	Description	Where Held		Current Market Value
91
92
93
94
95
96
97				Total	0
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99
100	SCHEDULE C – NON-READILY MARKETABLE SECURITIES