| TYPICAL STATEMENT OF PERSONAL NET WORTH |
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DATE:_______________________ |
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NAME:______________________ |
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ADDRESS:___________________ |
| GENERAL INFORMATION |
| Phone:Home __________________ |
Business ______________________ |
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| Present Employer |
Position Occupied |
How long with this employer |
| ____________________________ |
____________________________ |
__________________________ |
| Previous Employer ____________________________________________ |
How long __________________ |
| Landlord _____________________ |
Address _____________________ |
Rental _____________________ |
| Salary, Wages or Commision per Anum $ ____________________________ |
Other Income pre Anum $____________________________ |
Source _____________________ |
| Guarantees on Debts of Others: Name_______________________________________________________ |
Amount _____________________ |
| Account _______________________ |
Address ___________________________________________________ |
| Lawyer _______________________ |
Address ___________________________________________________ |
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| Assets |
| Bank Accounts |
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| Stocks at Cost (Market Value _____________) |
______________ |
| Bonds at Cost (Market Value _____________) |
______________ |
| Life Insurance (Cash Surrender Value) |
|
|
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Beneficiary_____________________ |
______________ |
| Automobile-Year________________ |
Make_________________________ |
______________ |
| Home-Mortgage Registered with |
_____________________________ |
______________ |
| - Building Size__________________ |
Lot Size_______________________ |
______________ |
| Other Assets |
|
______________ |
| Total |
|
______________ |
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| LIABILITIES |
| Bank Loan |
|
______________ |
| Charge Accounts |
|
______________ |
| Policy Loans and Life Insurance |
|
______________ |
| Other Loans |
|
______________ |
| Instalment Purchases |
|
______________ |
| Mortgages: Int.Rate__________ Term___________ Payments____________ |
______________ |
| Taxes |
|
______________ |
| Other Liabilities |
|
______________ |
| Sub Total |
|
______________ |
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| NET WORTH (Total Assets less Total Liabilities) |
______________ |
