Fillable Printable Income Tax Calculation Statement Form
Fillable Printable Income Tax Calculation Statement Form
Income Tax Calculation Statement Form
PERSONAL FINANCIAL STATEMENT
As of ,
Complete this form for each applicant. List only those assets you want to be considered in this personal financial statement.
Name
Business Phone
Address Residence Phone
City, State, & Zip Code
ASSETS
Cash on hand & in Banks
Savings Accounts
IRA or Other Retirement Account
Accounts & Notes Receivable
Life Insurance-Cash Surrender Value Only
(Complete Section 8)
Stocks and Bonds
(Describe in Section 3)
Real Estate
(Describe in Section 4)
Automobile-Present Value
Other Personal Property
(Describe in Section 5)
Other Assets
(Describe in Section 5)
Total
Section 1. Source of Income
Salary
Net Investment Income
Real Estate Income
Other Income (Describe below)*
Description of Other Income in Section 1.*
(Omit Cents)
LIABILITIES
(Omit Cents)
$
Accounts Payable
$
$
Notes Payable to Banks and Others
$
$
(Describe in Section 2)
$
Installment Account (Auto)
$
$
Mo. Payments
$
Installment Account (Other)
$
$
Mo. Payments
$
Loan on Life Insurance
$
$
Mortgages on Real Estate or Rent listed per month
$
(Describe in Section 4)
$
Unpaid Taxes
$
$
(Describe in Section 6)
All other Liabilities such as liens, judgments
$
$ (Describe in Section 7)
Total Liabilities
$
Net Worth
$
$
Total
$
Contingent Liabilities
$
As Endorser or Co-signer
$
$
Legal Claims & Judgments
$
$ $
$
Other contingent liabilities not listed.
*NOTE: Alimony or child support payments do not need to be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.
List loans, mortgages, credit card accounts, and other indebtedness. (Use attachements if necessary.
Each attachment must be identified as a part of this statement and signed.)
Section 2. Loans Payable to Banks and Others.
Original Current Payment Frequency How Secured or Endorsed
Name and Address of Noteholder(s)
Balance Balance Amount (monthly,etc.)
Type of Collateral if applicable.
Submit by Em ailPrint Form
Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).
Number of Shares Name of Securities Cost
Market Value Date of
Total Value
Quotation/Exchange Quotation/Exchange
Section 4. Real Estate Owned.
(List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part
of this statement and signed.)
Property A Property B Property C
Type of Property
Address
Date Purchased
Original Cost
Present Market Value
Name of Mortgage Holder
Mortgage Balance
Amount of Payment per Month/Year
Status of Mortgage
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms
Section 5. Other Personal Property and Other Assets.
of payment and if delinquent, describe delinquency)
Section 6. Unpaid Taxes.
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)
Section 7. Other Liabilities.
(Describe in detail.)
Section 8. Life Insurance Held.
(Give face amount and cash surrender value of policies - and name of insurance company.
I hereby affirm that this personal financial statement contains no willful misrepresentation or falsifications and this information given by me/us is true and
complete to the best of my/our knowledge and belief.
Signature: Date:
Signature: Date:
