Calculate Your Net Worth

Assets (OMIT CENTS)		Liabilities (OMIT CENTS)
Cash on hands & in Banks	$	Accounts Payable	$
Savings Accounts	$	Notes Payable to Banks and Others	$
IRA or Other Retirement Account	$	Installment Account (Auto)	$
Accounts & Notes Receivable	$	Mo. Payments $
Life Insurance-Cash Surrender Value Only	$	Installment Account (Other)	$
Stocks and Bonds	$	Mo. Payments $
Real Estate	$	Loan on Life Insurance	$
Automobile-Present Value	$	Mortgages on Real Estate	$
Other Personal Property	$	Unpaid Taxes	$
Other Assets	$	Other Liabilities	$
Total	$	Total Liabilities	$
		Net Worth	$
		Total	$

Section 1. Source of Income		Contingent Liabilities
Salary	$	As Endorser or Co-Maker	$
Net Investment Income	$	Legal Claims & Judgments	$
Real Estate Income	$	Provision for Federal Income Tax	$
Other Income (Describe below)	$	Other Special Debt	$

Description of Other Income in Section 1.

Section 2. Notes Payable to Bank and Others. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)
Name and Address of Noteholder(s)	Original Balance	Current Balance	Payment Amount	Frequency (monthly, etc.)	How Secured or Endorsed Type of Collateral
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$

Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed).
Number of Shares	Name of Securities	Cost	Market Value Quotation/Exchange	Date of Quotation/Exchange	Total Value
		$	$		$
		$	$		$
		$	$		$
		$	$		$
		$	$		$

Section 4. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)