NAME:
ADDRESS:
FILL IN ALL BLANKS, WRITING "NO" OR "NONE" WHERE NECESSARY
ASSETS			AMOUNT	LIABILITIES			AMOUNT
Cash in Banks				Notes payable:
Savings & Loan Shares				to banks
Earnest Money Deposited				to relatives
Investments (bonds & stocks)				to others
--see schedule				Installment Accts. Payable			$0
Investment in own business				automobile loans
Accounts/Notes Receivables			-	other accounts payable
Real Estate owned				other
--see schedule				Mortgages payable on real estate
	Year	Make		--see schedule
Automobiles
Personal property/furniture				Unpaid real estate taxes
Life Insurance				Unpaid income taxes
(Cash Surrender Value)				Chattel mortgages
Other assets (itemize)				Loans on life insurance
Jewelry				(include premium advance)
Art by estimate				Other debts - itemize
Retirement				Credit cards payable
				TOTAL LIABILITIES			$0
				NET WORTH (Assets)			$0
TOTAL ASSETS			$0	TOTAL LIABILITIES &
				NET WORTH			$0
SOURCE OF INCOME				PERSONAL INFORMATION
Base salary				Occupation/Type of Business
Overtime Wages			-
Dividends/interest income
Real estate income (net)
Spouse's Income
Other income
--itemize profits
TOTAL			$0
CONTINGENT LIABILITIES
As endorser/co-maker on notes
Alimony payments (annual)
Are you defendant in any
legal action?
Are there unsatisfied
judgements?
Have you ever taken
bankruptcy? (Explain)