Financial (Confidential) 

YOUR ASSETS
(current market value)

Cash In Banks
(Checking and Savings)

$___________
Life Insurance-
Cash Value

$___________
Marketable Securities $___________
Real Estate:          Home $___________

Office         

$___________
Automobiles
Other Assets (list)		 $___________

__________________

 $___________

__________________

 $___________

Total Assets

 $___________

YOUR LIABILITIES
   

Loans & Note Payable
(list in schedule below)		 $________
Charge Accounts Payable $________
Loans Against Life Insurance
(list in schedule below)		 $________
Real Estate Mortgages
(list in schedule below)		 $________
Other Liabilities (list) $________
__________________ $________
__________________ $________

Total Liabilities

 $________

Net Worth

 $________
How much capital can you initially invest in your own business? $ ____________________
Sources of additional capital if needed (show amount & source) _______________________
________________________________________________________________________
________________________________________________________________________
I have additional income (i.e. pensions, trusts, investments, ect.) in the amount of $ __________
per year from source(s) ______________________________________________________ 
What minimum annual income do you require? $___________________
Do you have any judgments or liens outstanding? ________________________________. 
If so, describe _____________________________________________________________
Have you, or any company that you had ownership in ever filed a petition for bankruptcy or made an assignment for the benefit of creditors? _______________________________.
Have you any lawsuits against you? __________________________________________.
If yes, describe ____________________________________________________________
________________________________________________________________________.

SCHEDULES OF NOTES, LOANS AND MORTGAGES PAYABLE
Amount To Whom Payable Date of Maturity Secured Unsecured
         
         
         
         
I certify that this is a true and complete statement of my financial position as of _______
__________, 20_______

Signature _____________________________________________

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