Personal Financial Statement Worksheet (5)

1 Personal Financial Statement WORKSHEETNAME:AS OF:ASSETSE stimatedLine #Fair on Hand$ in Bank (Schedule A)- & Contracts Receivable (Schedule B)- , Bonds & Mutual Funds - Listed (Schedule C)- & Bonds - Unlisted (Schedule D)- Estate & Buildings (Schedule E)- & Equipment (Costs $) , Fixtures & Personal Property (Schedule F)- & Trucks (Schedule G)- Value of Life Funds (Schedule H)- Retirement Plans (Schedule I)- OTHER ASSETS (Describe) 13. 14. ASSETS-$ Cards & Installation Purchases (Schedule J)-$ & Contracts Payable (Schedule K)- & Contracts on Real Estate (Schedule E)- & Truck Loans (Schedule G)- OTHER LIABILITIES (Describe) 20. 21. LIABILITIES-NET WORTH-$ Fill the attached schedules and the line items on page 1 will ACASH IN BANKShow all Checking, Savings, Certificates, Etc.* Type (1) Checking, (2) Savings, (3) Time CertificateBANK NAME/ BRANCH*TYPEINTEREST RATEMATURITY DATEAMOUNTTOTAL TO LINE 2-$ SCHEDULE BNOTES & CONTRACTS RECEIVABLEDUE FROM (NAME)DATE OFBALANCETERMS &DUEDESCRIPTION OFOBLIGATION ORIGINALPRESENTINT.

2 RATEDATE COLLATERAL IF ANYTOTAL TO LINE 3-$ SCHEDULE CSTOCKS, BONDS & MUTUAL FUNDSNO. OF SHARESDESCRIPTION - RATE - MATURITY, IF PLEDGED TO WHOMORIGINAL COSTMARKET VALUETOTAL TO LINE 4-$ SCHEDULE DSTOCKS & BONDS - UNLISTEDNO. OF SHARESDESCRIPTION - RATE - MATURITY, IF PLEDGED TO WHOMORIGINAL COSTMARKET VALUETOTAL TO LINE 5-$ NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)SCHEDULE EREAL ESTATE* Show Amount of Delinquent Taxes on each Propertyunder Mortgages. If Due in Installments, Show Amount and Whether Payment Includes Interest and at What &TITLE INCOMEMORTGAGESLOCATION OF PROPERTYDATE ACQUIREDIN NAME OFPER MONTHORIGINAL COSTMARKET VALUEPRESENT BALANCETERMS & INT. RATEHOLDER OF LIENR esidence$TOTAL TO LINE 6-$ TOTAL TO LINE 18-$ SCHEDULE FFURNITURE, FIXTURES, Personal PROPERTYD escription and if Amount Owed, to WhomAmount Owed Interest RateOriginal CostMarket ValueJewelry$Household ItemsTOTAL TO LINE 8-$ SCHEDULE GAUTO & TRUCKSTITLELOANYEAR/MAKE/MODELDATEIN NAME ORIGINAL MARKET PRESENT TERMS &HOLDERACQUIREDOFCOSTVALUE BALANCE INT.

3 RATEOF LIENTOTAL TO LINE 9-$ TOTAL TO LINE 19-$ NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)SCHEDULE HIRA FUNDS (TRADITIONAL & ROTH)OWNERDESCRIPTION - RATE - MATURITY MARKET VALUETOTAL TO LINE 11-$ SCHEDULE IQUALIFIED RETIREMENT PLANS OWNERDESCRIPTION - RATE - MATURITY ORIGINAL COSTMARKET VALUETOTAL TO LINE 12-$ SCHEDULE JCREDIT CARDS & INSTALLATION PURCHASESDUE TODATEBALANCETERMS & DUEDESCRIPTION OF (NAME)INCURREDORIGINAL PRESENT INT. RATEDATECOLLATERAL IF ANYTOTAL TO LINE 16-$ SCHEDULE KNOTES & CONTRACTS PAYABLEDUE TODATEBALANCETERMS & DUEDESCRIPTION OF (NAME)INCURREDORIGINAL PRESENT INT. RATEDATECOLLATERAL IF ANYTOTAL TO LINE 17-$ TRADITIONAL OR ROTH?NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)Do you have any current or pending judgments, suits or liabilities other then those mentioned above?

4 Yes NoIf yes, give details and the amount or expected amount of INFORMATION :BIRTHDAYAGESOCIAL SECURITY#(H)(W)(CH)EMPLOYMENTHUSBANDE mployerPositionSalaryOther income : SourceAmountWIFENAMERETIREMENT AND ESTATE PLANNING INFORMATIONRETIREMENT BENEFITSAge HowMonthly IncomeMonthly IncomePerson CoveredBeginsFundedDuring Lifefor Survivors$$TOTALS-$ -$ ESTATE PLANNINGW ills: YesNoDrawn by attorney? _____ Who?Gifts (contemplated or given):Trusts: Grantor:Beneficiary: Trustee:Principal: Objective:Comments:Pending Inheritance:Other Comments:NOTE: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)INSURANCE INFORMATIONI nsurance AdvisersNameAddressesLife Insurance (include group)LOANSPERSONFACETYPE OFANNUALCASHOUT-NETINSUREDINSURERAMOUNTP OLICYPREMIUMVALUESTANDINGAMOUNT$$ $$$ $$$ $$$ $$$ $$$ $$$ $$$ $$$ $$$ $Disability Insurance (include group)COVERAGEPERSONINSURER/ANNUAL1ST 4 5 MONTHSINSUREDSOURCEPREMIUMCOVERAGECOVERA GEWITH DEPENDENTS$$$$$$$$$$Total Estimated Monthly IncomeFrom Disability Insurance:-$ Health/Medical Insurance: Limits of Coverage (annual)PERSONANNUAL"BASIC" HOSPITALMAJORMEDI-OTHERINSUREDPREMIUMAND SURGICALMEDICALCARECOVERAGE$$$$$$$$$Comm ents:$$$-$ $$$$$$$$$$-$ $$$NOTE.

5 ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)MONTHLY income & EXPENSEGROSS income PER MONTH8. Entertainment & RecreationSalaryEatingOutInterestBaby SittersDividendActivities / TripsOtherVacation- Other- LESS:1. Tax9. Clothing(Est. - Incl. Fed., State, FICA)10. Savings2. Charitable Gifts11. Medical ExpensesNET SPENDABLE income - DoctorDentist3. HousingDrugsMortgage (rent)OtherInsurance- TaxesElectricity12. MiscellaneousGasToiletry,cosmeticsWaterB eauty,barberSanitationLaundry,cleaningTe le/Internet/CellAllowance,lunchesMainten anceSubscriptionsOtherGifts (incl. Christmas)- CashOther4. Food- 5. Automobiles(s)13. School / Child CarePaymentsTuitionGas & OilMaterialsInsurancesTransportationLice nse / TaxesDay CareMaint / Repair / Replace- - 14. Investments6. InsuranceLifeTOTAL expenses - MedicalOtherINCOME VS EXPENSE- Net Spendable income - Less expenses - 7. DebtsCredit CardLoans & NotesOther15. Unallocated Surplus income - - Modified From A Similar Spreadsheet Found In "The Family Budget Workbook" by Larry Burkett, Northfield Publishing, : ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)