Certificate of Financial Status Applicants’ Names: Jane ___________________________________ and John Doe Annual Income:
Self/Wife Self/Husband
Other Annual Income:
Self/Wife Self/Husband
Life Insurance:
Self/Wife Self/Husband
ASSETS:
This year $ 52,000.00 $ 52,000.00 2,500.00 2,500.00 $ 700,000.00 $ 700,000.00
Personal Property (Vehicles and Others)
VALUE $ 60,000.00
Real Estate: Residence and Other
$ 300,000.00
Stocks/Bonds
$
Savings Account(s)
$ 20,000.00
Checking Account(s)
$ 5,000.00
Other Investments
$ 200,000.00
TOTAL ASSETS: (Not including income & insurance)
$ 585,000.00
LIABILITIES: Credit Cards
MONTHLY PAYMENT: $ 0.00
$ 0.00
Home Mortgage
$ 1,500.00
$ 115,000.00
Other Liabilities
$ 250.00
$ 10,000.00
Last year $ 50,000.00 $ 50,000.00 2,500.00 2,500.00 700,000.00 700,000.00
TOTAL OWED:
TOTAL LIABILITIES:
$ 125,000.00
NET WORTH:
$ 460,000.00
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 __________________________ Texas County of Travis 17 Subscribed and sworn before me this 3rd _______________ day of ______________ 20_____. February ____________________________ Signature and seal
