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Section 4 – Annual Income For Year Ended ,

Annual Income

Individual

Joint

Annual Expenditure

Individual

Joint

Contigent Liabilities Estimated Amounts

Individual

Joint

Salary, bonuses & commissions

$

$

Mortgage/rental payments

$

$

Do you have any..Yes  No

$

$

Dividends & interest

$

$

Real-estate taxes & assessments

$

$

Contingent liabilities

(as endorser,

Co-maker or

Guarantor?)…           

$

$

Real estate income

$

$

Taxes-federal, state & local

$

$

(On leases?

On contracts?)           

$

$

Other income

(alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)

$

$

Insurance Payments

$

$

Involvement in

pending legal

actions?                     

$

$

$

$

Other contract payments (car payments, charge cards, etc.)

$

$

Contested income

tax liens?                   

$

$

$

$

Alimony, child support, maintenance

$

$

Any estimated

capital gains tax

on the unrealized

asset appreciation?   

$

$

$

$

Other expenses

$

$

Other special debt

or circumstances?      

$

$

Total Income

$

$

Total Expenditures

$

$

If ‘yes’ to any question(s) describe:

Total Cont. Liabilities

$

$

SCHEDULE A – CASH, CHECKING AND SAVINGS ACCOUNTS, CERTIFICATES OF DEPOSIT, MONEY MARKET FUNDS, ETC.

Name of Financial Institution

Type of Account

Owner

(J)

If Pledged, to Whom?

Balance

SCHEDULE B – U. S. GOVERNMENT & MARKETABLE SECURTIES (Use additional sheet if necessary)

Number of Shares or Face Value of Bonds

Description

In Name of

Are these Registered, Pledged, or Held by Others?

Market Value

Exchanges Where Traded

SCHEDULE C – NON-MARKETABLE SECURITIES (Use additional sheet if necessary)

Number of Shares

Description

In Name of

Are these Registered, Pledged, or Held by Others?

Value

Method of Valuation

SCHEDULE D – INVESTMENTS IN REAL ESTATE (Use additional sheet if necessary)

Description/Location of Real Estate Investment

(J)

Date of Original Investment/Amount

% Owned By You

Market Value of Your % of Investment

Present Balance

Monthly Payment

Mortgage Maturity Date

Mortgaged Owed To

SCHEDULE E – LIFE INSURANCE CARRIED, INCLUDING GROUP INSURANCE

Name of Insurance Company

Owner of Policy

Beneficiary and Relationship

Face Amount

Policy Loans

Cash Surrender Value

SCHEDULE F – VESTED INTEREST IN DEFERRED COMPENSATION/PROFIT-SHARING PLANS

% Vested

Company Name

Account Number

Manner of Payout (Annuity, Lump Sum, etc.)

Distribution Date

Beneficiary

Amount

SCHEDULE G – BUSINESS VENTURES (Use additional sheets if necessary)

List Name and Address of Any Business Venture In Which You Are a Principal Partner

Your Position/Title in Business

Line of Business

Years in Business

Total Assets Listed in Section 3

Your % of Ownership

Net Worth of Business

Present Net Value of Your Investment

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