LABOR DEPARTMENT PERSONAL FINANCIAL STATEMENT Name Date Home Address (Number & Street (City) Assets Cash_______________________________________________ _ (State) (Zip) Amount Liabilities Amount Notes Payable: 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._________________________________________________ __ 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 INCOME ANNUAL EXPENDITURES (Excluding ordinary living expense ) Salary______________________________________________ _ Real Estate Payment(s)____________________________________ Salary (Wife or Husband)________________________________ Rent_________________________________________________ __ Securities Income______________________________________ Income Taxes___________________________________________ Rentals_____________________________________________ _ Insurance Premiums______________________________________ Other (describe) Property Taxes__________________________________________ American LegalNet, Inc. www.USCourtForms.com 1._________________________________________________ __ Other (describe, include installment payments other than Real Estate): 2._________________________________________________ __ 3._________________________________________________ __ 1.___________________________________________________ __ 4._________________________________________________ __ 2.___________________________________________________ __ TOTAL INCOME_____________________ TOTAL EXPENDITURES_____________________ Total Expenditures_____________________________________ NET CASH INCOME: (exclusive of ordinary living expenses) Page 1 of 2 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 Name of Company Automobile Insurance: Public Liability: Yes Comprehensive personal Liability: Note: No Property Damage: Yes Yes No No 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 American LegalNet, Inc. www.USCourtForms.com NOTARIZATION: Subscribe and sworn to before me this day of 19 My commission expires on: * seal * Notary Public Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com