FINANCIAL STATEMENT ...................................................................... Name Date of Birth Social Security Number ...................................................................... Address Telephone Number ...................................................................... Employer Employers Address ...................................................................... Position held Employers Telephone Number If unemployed: How long.............Why ............................................. Previous Employer ..............................Position ............. Physical or mental disability ........................ ................Income Gross Pay $. .............,weekly $....................last year Net Pay $................weekly $. ...................per month Social Security, pension, retirement income $ ..............per monthUnemployment disability, workers compensation $...........per monthPublic assistance (Welfare, AFDC, SSI, VA) $...............per monthChild support or alimony income $...........weekly $ .......per monthOther income $. ......................Source .......................... ................... ................................................... Assets Property owned ................................. Value $ ...............P.I.T. payments $.............................. Bal. Due $ .............Name of Bank ..................................Mtg. Bal.$............. Car .....................Year and make .............Value $........... Bank accounts .....Checking $..............Savings $.................. Names of banks ....................................................... ...................................................................... Other assets ......................................................... ...................................................................... ...................................................................... ...................................................................... >>>> 2 2Liabilities ........................................................................................................................................................................................................................................................................................Current Income and Expenses (from all sources) Gross (weekly) (monthly) income $ ............................... Federal tax .......................... State tax ............................ Social Security ...................... Health Insurance ..................... Pension .............................. Other ......... ....................... ...................................... ...................................... ...................................... Total Deductions $......................... Net (weekly) (monthly) income $ ................. Rent $................................ Heat $................................ Gas $ ................................ Electric $ ........................... Food $ ............................... Clothing $ ........................... Other $ .............................. ..... ................................. ...................................... Total Expenses $............................ Net Income minus expenses $ ..................... Persons Living with you: .............................................Other facts relevant to ability to pay: ................................................................................................................................................................................................................................................ Signed under the penalties of perjury: ______________________________________ Name: ________________________________ Address: _____________________________ ______________________________________ Telephone No. ________________________ Date: ................