Certificate of Financial Status - gwca.org

Certificate of Financial Status . Applicants’ Names: _____ This year . Last year Annual Income: Self/Wife $ $...

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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