STATEMENT OF FINANCIAL CONDITION

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Eleanore Jackson
5 years ago
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1 STATEMENT OF FINANCIAL CONDITION AS OF ASSETS: LIABILITIES AND NET WORTH: Cash $ - Notes Due to Banks $ - Cash Value of Life Insurance - Notes Due to Others - Marketable Securities - Notes & Other Receivables - Bills Payable - Subtotal - Real Estate Mortgages - Income Taxes Payable - Real Estate Owned - Loans on Life Insurance Policies - Closely-Held Companies - Retirement Funds - Other Debt - Other Investments - Personal Property - Other Assets - Subtotal Total Debt - Subtotal - Net Worth - Total Assets $ - Total liabilities and net worth $ -

2 SCHEDULE A NET WORTH SUMMARY INDIVIDUAL - AS OF ASSETS: LIABILITIES AND NET WORTH: Cash $ - Notes Due to Banks $ - Cash Value of Life Insurance - Notes Due to Others - Marketable Securities - Notes & Other Receivables - Bills Payable - Subtotal - Real Estate Mortgages - Income Taxes Payable - Real Estate Owned - Loans on Life Insurance Policies - Closely-Held Companies - Retirement Funds - Other Debt - Other Investments - Personal Property - Other Assets - Subtotal Total Debt - Subtotal - Net Worth - Total Assets $ - Total liabilities and Net Worth $ - NET WORTH SUMMARY SPOUSE - AS OF ASSETS: LIABILITIES AND NET WORTH: Cash $ - Notes Due to Banks $ - Cash Value of Life Insurance - Notes Due to Others - Marketable Securities - Notes & Other Receivables - Bills Payable - Subtotal - Real Estate Mortgages - Income Taxes Payable - Real Estate Owned - Loans on Life Insurance Policies - Closely-Held Companies - Retirement Funds - Other Debt - Other Investments - Personal Property - Other Assets - Subtotal Total Debt - Subtotal - Net Worth - Total Assets $ - Total liabilities and Net Worth $ -

3 SCHEDULE B PERSONAL FINANCIAL STATEMENT DETAIL SCHEDULES - Page 1 INDIVIDUAL'S NAME: SPOUSE'S NAME (if applicable) DATE OF ASSET VALUATION CASH - TAXPAYER ACCOUNT AVERAGE NAME OF BANK, BANK OFFICER TYPE BALANCE SAVINGS CHECKING TOTAL CASH - CASH - SPOUSE ACCOUNT AVERAGE NAME OF BANK, BANK OFFICER TYPE BALANCE SAVINGS TOTAL CASH - CASH - JOINT ACCOUNT AVERAGE NAME OF BANK, BANK OFFICER TYPE BALANCE SAVINGS CHECKING TOTAL CASH - LIFE INSURANCE POLICIES TAXPAYER POLICY FACE CASH SURR'DER POLICY LOANS POLICY PREMIUM COMPANY/LOCATION OF POLICY AMOUNT VALUE OWED OWNER BENEFICIARY PREMIUM PAID BY LIFE INSURANCE POLICIES SPOUSE POLICY FACE CASH SURR'DER POLICY LOANS POLICY PREMIUM COMPANY/LOCATION OF POLICY AMOUNT VALUE OWED OWNER BENEFICIARY PREMIUM PAID BY MARKETABLE SECURITIES - TAXPAYER #SHARES/DESCRIPTION -OR- MARKET MARGIN BROKERAGE ACCOUNT/BROKER COST VALUE BALANCE - MARKETABLE SECURITIES - SPOUSE #SHARES/DESCRIPTION -OR- MARKET MARGIN BROKERAGE ACCOUNT/BROKER COST VALUE BALANCE - MARKETABLE SECURITIES - JOINT #SHARES/DESCRIPTION -OR- MARKET MARGIN BROKERAGE ACCOUNT/BROKER COST VALUE BALANCE - NOTES & OTHER RECEIVABLES - TAXPAYER ORIGINAL BALANCE PAYMENT DEBTOR/DESCRIPTION DUE DATE AMOUNT DUE TERMS COLLATERAL

4 SCHEDULE B (continued) PERSONAL FINANCIAL STATEMENT DETAIL SCHEDULES - Page 2 NOTES & OTHER RECEIVABLES - SPOUSE ORIGINAL BALANCE PAYMENT DEBTOR/DESCRIPTION DUE DATE AMOUNT DUE TERMS COLLATERAL NOTES & OTHER RECEIVABLES - JOINT ORIGINAL BALANCE PAYMENT DEBTOR/DESCRIPTION DUE DATE AMOUNT DUE TERMS COLLATERAL REAL ESTATE OWNED/MORTGAGES PAYABLE - TAXPAYER MORTGAGE PAYABLE OWNER/ DATE COST/ MARKET INSURED BALANCE DESCRIPTION & LOCATION TITLE ACQUIRED BASIS VALUE VALUE DUE PAYMENT MATURITY CREDITOR - - REAL ESTATE OWNED/MORTGAGES PAYABLE - SPOUSE MORTGAGE PAYABLE OWNER/ DATE COST/ MARKET INSURED BALANCE DESCRIPTION & LOCATION TITLE ACQUIRED BASIS VALUE VALUE DUE PAYMENT MATURITY CREDITOR REAL ESTATE OWNED/MORTGAGES PAYABLE - JOINT MORTGAGE PAYABLE OWNER/ DATE COST/ MARKET INSURED BALANCE DESCRIPTION & LOCATION TITLE ACQUIRED BASIS VALUE VALUE DUE PAYMENT MATURITY CREDITOR - -

5 SCHEDULE B (continued) PERSONAL FINANCIAL STATEMENT DETAIL SCHEDULES - Page 3 CLOSELY HELD COMPANIES-TAXPAYER ENTITY % DATE COST MARKET COMPANY NAME INDUSTRY TYPE OWNED ACQ BASIS VALUE VALUATION BASIS OWNER ESTIMATE CLOSELY HELD COMPANIES -SPOUSE ENTITY % DATE COST MARKET COMPANY NAME INDUSTRY TYPE OWNED ACQ BASIS VALUE VALUATION BASIS OWNER ESTIMATE RETIREMENT FUNDS-TAXPAYER ACCOUNT CURRENT MARKET DESCRIPTION/BROKERAGE TYPE CONTRIB. VALUE OWNER % VESTED IRA 401K RETIREMENT FUNDS-SPOUSE ACCOUNT CURRENT MARKET DESCRIPTION/BROKERAGE TYPE CONTRIB. VALUE OWNER % VESTED IRA 401K OTHER INVESTMENTS - TAXPAYER PERSONAL PROPERTY OTHER ASSETS MARKET VALUE LOANS ON PROPERTY DATE COST/ OTHER PERSONAL OTHER BALANCE DESCRIPTION ACQ'D BASIS INVEST PROPERTY ASSETS DUE CREDITOR HOUSEHOLD ITEMS AUTO OTHER INVESTMENTS - SPOUSE PERSONAL PROPERTY OTHER ASSETS MARKET VALUE LOANS ON PROPERTY DATE COST/ OTHER PERSONAL OTHER BALANCE DESCRIPTION ACQ'D BASIS INVEST PROPERTY ASSETS DUE CREDITOR HOUSEHOLD ITEMS AUTO - - -

6 SCHEDULE B (continued) PERSONAL FINANCIAL STATEMENT DETAIL SCHEDULES - Page 4 OTHER INVESTMENTS - JOINT PERSONAL PROPERTY OTHER ASSETS MARKET VALUE LOANS ON PROPERTY DATE COST/ OTHER PERSONAL OTHER BALANCE DESCRIPTION ACQ'D BASIS INVEST PROPERTY ASSETS DUE CREDITOR HOUSEHOLD ITEMS AUTO NOTES PAYABLE/CREDIT CARDS PAYABLE - TAXPAYER NATURE OF DEBT MATURITY DUE TO DUE TO BILLS INCOME OTHER CREDITOR/PAYABLE TO DATE BANKS OTHERS PAYABLE TAXES PAY DEBT PAYMENTS COLLATERAL AMEX VISA IRS MARGIN ACCOUNT BALANCE DEBT OWED, PERS PROPERTY & OTHER NOTES PAYABLE/CREDIT CARDS PAYABLE - SPOUSE NATURE OF DEBT MATURITY DUE TO DUE TO BILLS INCOME OTHER CREDITOR/PAYABLE TO DATE BANKS OTHERS PAYABLE TAXES PAY DEBT PAYMENTS COLLATERAL AMEX VISA IRS MARGIN ACCOUNT BALANCE DEBT OWED, PERS PROPERTY & OTHER NOTES PAYABLE/CREDIT CARDS PAYABLE - JOINT NATURE OF DEBT MATURITY DUE TO DUE TO BILLS INCOME OTHER CREDITOR/PAYABLE TO DATE BANKS OTHERS PAYABLE TAXES PAY DEBT PAYMENTS COLLATERAL AMEX VISA IRS MARGIN ACCOUNT BALANCE DEBT OWED, PERS PROPERTY & OTHER - - -

7 SCHEDULE C INCOME AND MISCELLANEOUS INFORMATION ESTIMATED ANNUAL INCOME: SALARY, BONUSES, COMMISSIONS (H) SALARY, BONUSES, COMMISSIONS (W) INTEREST & DIVIDEND INCOME SCHEDULE C INCOME (NET) CAPITAL GAINS/LOSSES-BROKERS CAPITAL GAINS/LOSSES-OTHER RENT INCOME (NET) S-CORP, PARTNERSHIP, ESTATE INCOME OTHER INCOME: AMOUNT TOTAL $ - ESTIMATED ANNUAL EXPENSES: RENT / MORTGAGE PAYMENTS VEHICLE PAYMENTS TUITION EXPENSES ALIMONY CHILD SUPPORT HOUSEHOLD EXPENSES OTHER AMOUNT TOTAL $ - CONTINGENT LIABILTIES: DO YOU HAVE ANY CONTINGENT LIABILITIES - AS ENDORSER, CO-MAKER OR GUARANTOR? ON LEASES OR CONTRACTS? ON LEGAL CLAIMS OTHER SPECIAL DEBT CONTESTED INCOME TAX LIENS AMOUNT OTHER: ARE YOU A U.S. CITIZEN ARE YOU A PARTNER OR OFFICER IN ANY OTHER VENTURE? DO YOU HAVE A WILL? IF SO, EXECUTOR NAME HAVE YOU CREATED ANY TRUSTS? ARE YOU THE BENEFICIARY OF ANY TRUSTS? DO YOU OWN ANY ASSETS FROM GIFT/INHERITANCE? DO YOU HAVE ANY UNEXERCISED STOCK OPTIONS? INCOME TAX SETTLED THROUGH (DATE) ARE YOU A DEFENDANT IN ANY SUITS OR LEGAL ACTIONS? IF SO, DESCRIBE HAVE YOU OR YOUR BUSINESSES EVER BEEN DECLARED BANKCRUPT? IF SO, DESCRIBE CIRCUMSTANCES

FINANCIAL STATEMENT - INDIVIDUAL

FINANCIAL STATEMENT - INDIVIDUAL TO FINANCIAL INSTITUTION NAMED: INDIVIDUAL DATE OF STATEMENT JOINT NAME OF INDIVIDUAL: HOME ADDRESS HOME PHONE SOCIAL SECURITY DATE OF BIRTH ASSETS (Omit Cents) LIABILITIES