Personal Financial Statement Worksheet (5)

PERSONAL FINANCIAL STATEMENT WORKSHEET

NAME: AS OF:

Line #

ASSETS

Fill the attached schedules and the line items on page 1 will calculate.

Estimated Fair Market

Value

1.

Cash on Hand

2.

Cash in Bank (Schedule A)

3.

Notes & Contracts Receivable (Schedule B)

4.

Stocks, Bonds & Mutual Funds - Listed (Schedule C)

5.

Stocks & Bonds - Unlisted (Schedule D)

6.

Real Estate & Buildings (Schedule E)

$

00000-

7.

Machinery & Equipment (Costs $

)

8.

Furniture, Fixtures & Personal Property (Schedule F)

9.

Auto & Trucks (Schedule G)

00-

10.

Cash Value of Life Insurance

11.

IRA Funds (Schedule H)

12.

Qualified Retirement Plans (Schedule I)

00-

OTHER ASSETS (Describe) 13. 14. 15.

TOTAL ASSETS

$

-

LIABILITIES

16.

Credit Cards & Installation Purchases (Schedule J)

17.

Notes & Contracts Payable (Schedule K)

18.

Mortgages & Contracts on Real Estate (Schedule E)

19.

Auto & Truck Loans (Schedule G)

$ 0000-

OTHER LIABILITIES (Describe) 20.

21.

22.

TOTAL LIABILITIES

-

NET WORTH

$

-

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS) SCHEDULE A

CASH IN BANK

Show all Checking, Savings, Certificates, Etc.

* Type (1) Checking, (2) Savings, (3) Time Certificate

BANK NAME/ BRANCH

*TYPE

INTEREST RATE

MATURITY DATE

AMOUNT

TOTAL TO LINE 2

$

0-

SCHEDULE B

DUE FROM (NAME)

NOTES & CONTRACTS RECEIVABLE

DATE OF

BALANCE

TERMS &

OBLIGATION ORIGINAL PRESENT INT. RATE

DUE DESCRIPTION OF DATE COLLATERAL IF ANY

TOTAL TO LINE 3

SCHEDULE C

NO. OF SHARES

$0 -

STOCKS, BONDS & MUTUAL FUNDS

DESCRIPTION - RATE - MATURITY, IF PLEDGED TO WHOM

ORIGINAL COST

MARKET VALUE

TOTAL TO LINE 4

SCHEDULE D

NO. OF SHARES

$ 0

-

STOCKS & BONDS - UNLISTED

DESCRIPTION - RATE - MATURITY, IF PLEDGED TO WHOM

ORIGINAL COST

MARKET VALUE

TOTAL TO LINE 5

$ 0

-

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS) SCHEDULE E

REAL ESTATE

* Show Amount of Delinquent Taxes on each Property

under Mortgages. If Due in Installments, Show Amount

and Whether Payment Includes Interest and at What Rate.

TYPE &

TITLE INCOME

MORTGAGES

LOCATION OF PROPERTY

DATE IN NAME PER ORIGINAL MARKET PRESENT TERMS & HOLDER OF

ACQUIRED

OF

MONTH COST VALUE BALANCE INT. RATE

LIEN

Residence

$

TOTAL TO LINE 6 TOTAL TO LINE 18

$0 -

$0 -

SCHEDULE F

FURNITURE, FIXTURES, PERSONAL PROPERTY

Description and if Amount Owed, to Whom

Amount Owed Interest Rate

Original Cost

Jewelry

Household Items

Market Value

$

TOTAL TO LINE 8

$ 0

-

SCHEDULE G

YEAR/MAKE/MODEL

DATE

AUTO & TRUCKS

TITLE

LOAN

IN NAME ORIGINAL MARKET PRESENT TERMS &

ACQUIRED OF

COST VALUE BALANCE INT. RATE

HOLDER OF LIEN

TOTAL TO LINE 9 TOTAL TO LINE 19

$0 -

$0 -

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS) SCHEDULE H

IRA FUNDS (TRADITIONAL & ROTH)

OWNER

TRADITIONAL OR ROTH?

DESCRIPTION - RATE - MATURITY

MARKET VALUE

TOTAL TO LINE 11

SCHEDULE I

OWNER

$ 0

-

QUALIFIED RETIREMENT PLANS

DESCRIPTION - RATE - MATURITY

ORIGINAL COST MARKET VALUE

TOTAL TO LINE 12

SCHEDULE J

DUE TO (NAME)

$ 0

-

CREDIT CARDS & INSTALLATION PURCHASES

DATE

BALANCE

TERMS & DUE

INCURRED ORIGINAL PRESENT INT. RATE DATE

DESCRIPTION OF COLLATERAL IF ANY

TOTAL TO LINE 16

SCHEDULE K

DUE TO (NAME)

$ -0

NOTES & CONTRACTS PAYABLE

DATE

BALANCE

TERMS & DUE

INCURRED ORIGINAL PRESENT INT. RATE DATE

DESCRIPTION OF COLLATERAL IF ANY

TOTAL TO LINE 17

$ -0

Do you have any current or pending judgments, suits or liabilities other then those mentioned above? Yes No

If yes, give details and the amount or expected amount of liability.

GENERAL INFORMATION :

(H) (W) (CH)

NAME

BIRTHDAY

AGE

SOCIAL SECURITY#

EMPLOYMENT

Employer Position Salary Other Income: Source

Amount

WIFE

HUSBAND

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS) RETIREMENT AND ESTATE PLANNING INFORMATION

RETIREMENT BENEFITS

Person Covered

Age Begins

How Funded

Monthly Income Monthly Income

During Life

for Survivors

$

$

TOTALS $

0- $

0-

ESTATE PLANNING

Wills:

Yes

No

Gifts (contemplated or given):

Trusts: Grantor: Trustee: Objective:

Comments:

Pending Inheritance:

Other Comments:

Drawn by attorney? ______ Who?

Beneficiary: Principal:

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS) INSURANCE INFORMATION

Insurance Advisers

Name

Addresses

Life Insurance (include group)

PERSON INSURED

INSURER

FACE AMOUNT

TYPE OF POLICY

ANNUAL PREMIUM

CASH VALUE

LOANS OUT-

STANDING

NET AMOUNT

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Disability Insurance (include group)

$

$

PERSON INSURED

INSURER/ SOURCE

ANNUAL 1ST MO. PREMIUM COVERAGE

NEXT 4 MO. COVERAGE

$

$

COVERAGE AFTER 5 MONTHS WITH DEPENDENTS

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Total Estimated Monthly Income

From Disability Insurance:

$

-

$

-

$

-

Health/Medical Insurance: Limits of Coverage (annual)

PERSON INSURED

ANNUAL PREMIUM

"BASIC" HOSPITAL AND SURGICAL

MAJOR MEDIMEDICAL CARE

OTHER COVERAGE

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Comments:

NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)

MONTHLY INCOME & EXPENSE

GROSS INCOME PER MONTH

8. Entertainment & Recreation

Salary

Eating Out

Interest

Baby Sitters

Dividend

Activities / Trips

Other

Vacation

0-

Other

0-

LESS:

1. Tax

9. Clothing

(Est. - Incl. Fed., State, FICA)

10. Savings

2. Charitable Gifts

11. Medical Expenses

NET SPENDABLE INCOME

-

Doctor

Dentist

3. Housing

Drugs

Mortgage (rent)

Other

Insurance

0-

Taxes

Electricity

12. Miscellaneous

Gas

Toiletry, cosmetics

Water

Beauty, barber

Sanitation

Laundry, cleaning

Tele/Internet/Cell

Allowance, lunches

Maintenance

Subscriptions

Other

Gifts (incl. Christmas)

0-

Cash

Other

4. Food

0-

5. Automobiles(s)

13. School / Child Care

Payments

Tuition

Gas & Oil

Materials

Insurances

Transportation

License / Taxes

Day Care

Maint / Repair / Replace

0-

14. Investments

6. Insurance

Life

TOTAL EXPENSES

Medical

Other

INCOME VS EXPENSE

0-

Net Spendable Income

Less Expenses

7. Debts

Credit Card

Loans & Notes

Other

15. Unallocated Surplus Income

0-

Modified From A Similar Spreadsheet Found In "The Family Budget Workbook" by Larry Burkett, Northfield Publishing, 1993.

0-

-

-

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