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? 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?

4 _____ 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: ENTER WHOLE NUMBERS ONLY IN THE COLUMNS THAT CALCULATE (NO SYMBOLS, COMMAS, OR PERIODS)MONTHLY INCOME & EXPENSEGROSS INCOME PER MONTH8.

5 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)