UDC_PFS_8.7.17
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Personal Financial Statement
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Name:Phone:
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Home Address:Email:
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City, State, Zip:Birthdate:
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Business Name:SSN:
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ASSETS
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Description Account Type LocationAmount
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CashSavings Account $ -
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CashChecking Account -
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InvestmentCertificate of Deposit -
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InvestmentStocks -
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InvestmentsMutual Funds -
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InvestmentsBonds -
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InvestmentsOther -
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Life InsuranceCash Surrender Value -
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Personal property Jewelry, Furnishings(list current cash value) -
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Personal property Automobile(list make, model and year) -
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Personal property Automobile(list make, model and year)
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Retirement Funds IRA, 401(k), Pension -
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Real estate Personal Home
(list address, appraised value)
-
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Real estate Investment Property -
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Other -
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Other -
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Other -
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Total Assets $ -
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LIABILITIES
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Description Account Type LocationAmount
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Credit CardBank $ -
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Credit CardBank -
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Credit CardStore -
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Credit CardStore -
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Credit CardStore -
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Line of CreditLoan -
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Unpaid TaxesDebt -
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Personal LoansOther -
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Bank LoansLoan -
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Auto Loan Loan -
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401(k) LoansLoan -
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Real estate Home Mortgage -
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Real estate
Investment Mortgage(s)
-
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Other -
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Other -
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Other -
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Total Liabilities $ -
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Net Worth $ -
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Answer the questions below. Your financial statement is incomplete without these answers.
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Have you provided a guaranty or co-signed any debts that are not listed above?Yes
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Are you a partner, owner or officer in any business or entity not listed above?Yes
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Are you obligated to pay alimony, child support, maintenance or restitution?Yes
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Are you currently a defendant in any legal suits or actions?Yes
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Have you or a related entity ever declared bankruptcy?Yes
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Certification and Authorization
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I hereby certify that all of the information listed herein is true, correct and complete as of the date listed below. I further authorize NewTown Macon to order a full credit report using the information contained in this statement.
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Signature:Date:
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