Certificate of Financial Status . Applicants’ Names: _____ This year . Last year Annual Income: Self/Wife $ $
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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: 2011 2010 Annual Income: Self/Wife $ $ Self/Husband $ $
State of Wisconsin . DEPARTMENT OF FINANCIAL INSTITUTIONS . Division of Corporate & Consumer Services . CERTIFICATE OF STATUS AND CERTIFIED COPY ORDER
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Certificate of Exemption and This
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CERTIFICATE OF FINANCIAL STATUS Applicant’s names: _______________________________________________________
Annual Income:
Other annual Income:
Life Insurance:
Self/wife
This Year =$___________
Last Year $____________
Self/husband
=$___________
$____________
Self/wife
=$___________
$____________
Self/husband
=$___________
$____________
Self/wife
=$___________
$____________
Self/husband
=$___________
$____________
ASSETS:
VALUE
Personal Property (vehicles and others)
$ ____________________
Real Estate: (residence and others)
$ ____________________
Stocks and Bonds
$ ____________________
Savings Account(s)
$ ____________________
Checking Account(s)
$ ____________________
Other Investment
$ ____________________
TOTAL ASSETS: (not including income & insurance)
LIABILITIES: Credit Cards Home Mortgage Other Liabilities
TOTAL OWED: $________________ $________________ $________________
TOTAL LIABILITIES:
$________________
NET WORTH:
$________________
I/We attest that the above-mentioned financial statement is an accurate summary of my/our assets, liabilities and others. ______________________________ _________________________________ Signature
Signature
State of _______________ County of _____________ Subscribed and sworn to before me this day of , 20____. by who is: personally known to me. produced their ____________________________ as identification.
