Certificate of Financial Status . Applicants’ Names: 2011 2010 Annual Income: Self/Wife $ $ Self/Husband $ $
Certificate of Financial Status . Applicants’ Names: _____ This year . Last year Annual Income: Self/Wife $ $
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CERTIFICATE OF FINANCIAL STATUS Applicant’s names: _____ This Year Last Year
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CERTIFICATE OF FINANCIAL STATUS (Please type. DO NOT handwrite.)
Applicant names: (first and last name of each adopting parent) 1._______________________________________ 2. _______________________________________ Income Information Annual Income
Other Annual Income
This year
Last Year
Single Applicant
=
$ _____________ _____________
Husband
=
$ _____________ _____________
Wife
=
$ _____________ _____________
Single Applicant
=
$ _____________ _____________
Husband
=
$ _____________ _____________
Wife
=
$ _____________ _____________
Assets:
Value: Personal Property (vehicles and others)
$ ________________________
Real Estate (residence and others)
$ ________________________
Stocks and Bonds
$ ________________________
Savings Account(s)
$ ________________________
Checking Account(s)
$ ________________________
Life Insurance
$ ________________________
Other Investments
$ ________________________
Total Assets: (Not including annual income)
0 $ ________________________
Liabilities:
Monthly Payment:
Total Owed:
Credit Cards
$ ________________________
$ ________________________
Home Mortgage
$ ________________________
$ ________________________
Other Liabilities
$ ________________________
$ ________________________
Total Liabilities:
0 $ ________________________
NET WORTH:
$
0 ________________________
I/We attest that the above-mentioned financial statement is an accurate summary of my/our assets, liabilities, and others.
