PERSONAL FINANCIAL STATEMENT

Prepared for

NAME:
ADDRESS:
	,
HOME PHONE:
CELL PHONE:
SSN:
BIRTHDATE:

[BF1]

DETAILED SUMMARY LISTING OF ASSETS

INDIVIDUAL ASSET INFORMATION	AMOUNT
Accounts Receivable:
Annuity:
Boats:
Bonds
Business Property and Real Estate:
Certificate of Deposit:
Checking Accounts:
Household Furnishings:
Jewelry:
Life Insurance:
Mutual Funds:
Notes Receivable:
Other Assets:
Other Real Estate:
Personal Residence Real Estate:
Recreational Equipment:
Retirement Plans:
Savings Accounts:
Stocks:
Trusts:
Vehicles

INDIVIDUAL TOTAL ASSET VALUE:	$0.00

[BF2]

DETAILED SUMMARY LISTING OF LIABILITIES

INDIVIDUAL LIABILITY INFORMATION	AMOUNT
Mortgage or Rent:
Home Equity Loan:
Other Mortgage:
Vehicle Loans:
Credit Cards:
Student Loans:
Other Liabilities:

INDIVIDUAL TOTAL LIABILITIES:	$0.00

[BF3]

DETAILED SUMMARY LIST OF MONTHLY INCOME ASSET

INDIVIDUAL MONTHLY INCOME	MONTHLY AMOUNT
Monthly Salary or Wages:
Investment Accounts:
Alimony:
Child Support:
Trusts:
Other Income Sources:

INDIVIDUAL TOTAL MONTHLY INCOME ASSET:	$0.00

[BF5]

DETAILED SUMMARY LIST OF MONTHLY EXPENSE LIABILITY

INDIVIDUAL MONTHLY EXPENSES	MONTHLY AMOUNT
Paid Alimony:
Paid Child Care:
Paid Child Support:
Groceries:
Healthcare or Medications:
Housing or Rent:
Other Mortgage Loans:
Auto Loans:
Auto Insurance:
Health or Dental Insurance:
Life Insurance:
Other Insurance:
Credit Cards:
Student Loans:
Other Expenses:

INDIVIDUAL TOTAL MONTHLY EXPENSE LIABILITY:	$0.00

[BF6]

NET WORTH SUMMARY

TOTAL ASSETS:	$0.00
TOTAL LIABILITIES:	$0.00
TOTAL NET WORTH:	$0.00

I, , hereby certify and warrant, to the best of my knowledge, that the aforementioned information contained within this Personal Financial Statement is true, accurate and complete.

		DATED:

[BF7]