Income Information. This year. Last Year. Annual Income. Single Applicant. = $ ______ ______. Husband. = $ ______ ______. Wife. = $ ______ ______. Other Annual Income. Single Applicant. = $ ______ ______. Husband. = $ ______ ______. Wife. = $ ______
Certificate of Financial Status . Applicants’ Names: _____ This year . Last year Annual Income: Self/Wife $ $
FINANCIAL STATEMENT FOR RESOURCE PARENTING. List All Outstanding Debts: (show total owed and monthly payments) Attach additional page if needed
CERTIFICATE OF FINANCIAL STATUS Applicant’s names: _____ This Year Last Year
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Certificate of Financial Status Applicants’ Names: 2011 Annual Income:
Self/Wife Self/Husband
Other Annual Income:
Self/Wife Self/Husband
Life Insurance:
Self/Wife Self/Husband
$ $
$ $
$ $
ASSETS:
VALUE
Personal Property (Vehicles and Others)
$
Real Estate: Residence and Other
$
Stocks/Bonds
$
Savings Account(s)
$
Checking Account(s)
$
Other Investments
$
TOTAL ASSETS: (Not including income & insurance)
$
LIABILITIES:
2010
MONTHLY PAYMENT:
TOTAL OWED:
Credit Cards
$
$
Home Mortgage
$
$
Other Liabilities
$
$
TOTAL LIABILITIES:
$
NET WORTH:
$
I/We attest that the above information is an accurate summary of my/our assets, liabilities and other information. Signature and Date
Signature and Date
State of __________________________ County of Subscribed and sworn before me this _______________ day of ______________ 20_________; ____________________________ Signature and seal
