Free PERSONAL.PDF - Arizona

LABOR DEPARTMENT
PERSONAL FINANCIAL STATEMENT Name Home Address (Number & Street (City) Assets Cash_______________________________________________ _ Accounts Receivable-Good______________________________ Stocks & Bonds(Schedule B)_____________________________ Other Notes Payable: Notes ReceivableGood_________________________________ Cash Surrender Value Life Ins.___________________________ Autos:______________________________________________ _ (Yr./Make) (Yr./Make) Accounts Payable________________________________________ Taxes Payable___________________________________________ Real Estate (Schedule A)________________________________ other assets (describe): 1._________________________________________________ __ (State) Amount Notes Payable: (Zip) Liabilities Amount Date

Contracts Payable________________________________________ To:__________________________________________________ To:__________________________________________________

2._________________________________________________ __ 3._________________________________________________ __ Real Estate Indebtedness (Schedule A Other Liabilities):

1.___________________________________________________ __ 2.___________________________________________________ __ 3.___________________________________________________ __ Other Liabilities:

TOTAL LIABILITES_____________________________________ NET WORTH___________________________________________ TOTAL ASSETS TOTAL_______________________________________________ _ ANNUAL EXPENDITURES (Excluding ordinary living expense ) Real Estate Payment(s)____________________________________ Rent_________________________________________________ __ Income Taxes___________________________________________ Insurance Premiums______________________________________ Property Taxes__________________________________________

ANNUAL INCOME

Salary______________________________________________ _ Salary (Wife or Husband)________________________________ Securities Income______________________________________ Rentals_____________________________________________ _ Other (describe)

1._________________________________________________ __ 2._________________________________________________ __ 3._________________________________________________ __ 4._________________________________________________ __ Other (describe, include installment payments other than Real Estate):

1.___________________________________________________ __ 2.___________________________________________________ __

TOTAL INCOME_____________________ Total Expenditures_____________________________________ NET CASH INCOME: (exclusive of ordinary living expenses) Page 1 of 2

TOTAL EXPENDITURES_____________________

What assets in this statement are in joint tenancy?________________________________________________________________________________________ Name of other party Are you a guarantor on anyone' debt? s If so, give details: Are any encumbered assets or debts secured except as indicated? If so, please itemize by debt and security ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Have you: (a) Ever been the subject of a voluntary or involuntary petition in bankruptcy?________________________________________________________ (b) Ever been adjudicated bankrupt?_________________________________________ Date_____________________________________________ (c) Ever been an officer or a partner in any establishment subject to a involuntary position in bankrupcty?___________________________________ (d) Ever been an officer or a partner in any establishement adjudicated bankrrupt?______________________________________________________ Have you ever been convicted of misappropriating funds? Yes ________ No___________ If yes, give details and dates:_________________________________________________________________________________________________________

SCHEDULE A - REAL ESTATE: Location and Type of Real Estate Title in Name of $ Estimated Value $ Amount Owing To Whom Payable

SCHEDULE B - STOCKS AND BONDS: Number of Shares Amount of Bonds Description $ Current Market Value on Listed $ Estimate Value on Unlisted

If additional space is needed for Schedule A and/or Schedule B, list on separate sheet and attach. INSURANCE: Life Insurance $ Beneficiary Automobile Insurance: Public Liability: Yes Comprehensive personal Liability: No Yes Property Damage: No Yes No Name of Company

Note:

It is a felony to knowingly file a false or forged instrument with a Public Office in this State (A.R.S. 39-161).

AFFIDAVIT: Under penalties of perjury, I declare and affirm that the statement made in the foregoing financial statement, including any accompanying attachment(s) are true, complete and correct.

Date

Signature

NOTARIZATION: My commission expires on:

Subscribe and sworn to before me this

day of

19

* seal * Notary Public

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