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PERSONAL BALANCE SHEET

STATE OF WASHINGTON DEPARTMENT OF FINANCIAL INSTITUTIONS SECURITIES DIVISION PO Box 9033 Olympia, WA 98501-9033 (360) 902-8815 PERSONAL BALANCE SHEET Rev. 03/ 2015 1. PERSONAL INFORMATION Full Legal Name: CRD: Email Address: Phone: 2. REVENUE INFORMATION Monthly Income: % in Commissions: % in Salary: 3. PERSONAL BALANCE SHEET Date Prepared: NOTE: All assets should be reported at market value and all liabilities should be reported at present value. ASSETS VALUE LIABILITIES VALUE Cash Home 1. Checking Account(s) 24. Mortgage 2. Savings Account(s) 25. Home Equity Line of Credit (HELOC) 3. Other: 26. Other: Investments Loans 4. Stocks 27. Vehicle Loan(s)* 5. Bonds 28. Credit Card Debt(s) 6. Certificates of Deposit (CDs) 29. PERSONAL Loan(s) 7. Mutual Funds 30. Student Loan(s) 8. Other: 31. Other: Retirement Other Liabilities 9. 401(k) or 403(b) 32. PERSONAL Estimated Taxes Payable 10.

state of washington department of financial institutions securities division po box 9033 olympia, wa 98501-9033 (360) 902-8815 lcie@dfi.wa.gov

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