Statement of Net Worth

Please submit the form below. Please submit the form below.

Statement of Net Worth
Name:	Address:
City:	State:	Zip:
Email Address:
Assets
Cash in Hand & In Banks:
Savings Accounts:
IRA:
Accounts & Notes Receivable:
Describe:

Life Insurance (Cash Surrender Value):
Real Estate:
Describe:

Automobile (Present Value):
Other Personal Property:
Describe:

Other Assets:
Describe:

TOTAL ASSETS:
Liabilities
Accounts Payable:
Notes Payable to Others:
Describe:

Installment Account (Auto):
Monthly Payments:
Installment Account (Other):
Monthly Payments:
Loans on Life Insurance:
Mortgage on Real Estate:
Unpaid Taxes:
Describe:

Other Liabilities:
Describe:

TOTAL LIABILITIES:
Service of Income
Salary:
Net Investment Income:
Real Estate Income:
Other Income:
Describe:

TOTAL INCOME:
TOTAL ASSETS:
TOTAL LIABILITIES:
NET WORTH:
Contingent Liabilities
As Endorser or Co-maker:
Legal Claims or Judgements:
Provision for Federal Income Tax:
Other Special Debt:
TOTAL CONTINGENT LIABILITY:
Date: