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SECTION 4. REAL ESTATE OWNED
Starting with your primary residence, enter the type of property, address, date purchased, original
cost, present fair market value, name and address of mortgage holder, mortgage account
number, mortgage balance, amount of payment, and status of mortgage for all real estate held.
Second mortgages also should be included in this section. Please ensure that this section
contains all real estate owned, including rental properties, commercial properties, etc.
These values should correspond with the "Real Estate" amount listed in the "ASSETS" column
SECTION 5. OTHER PERSONAL PROPERTY
Describe the "Other Personal Property" and "Other Assets" owned as listed in the "ASSETS"
column.
SECTION 6. UNPAID TAXES
Describe in detail, as to the type, to whom payable, when due, amount, and to what property, if
any, the tax lien attaches. Please refer to the unpaid taxes listed in the "LIABILITIES" column. If
none, state NONE. This section should not include contingent tax liabilities or anticipated taxes
owed for the current year.
SECTION 7. OTHER LIABILITIES
Describe in detail all other liabilities as referenced by the value listed in the "LIABILITIES"
column. If none, state NONE.
SECTION 8. LIFE INSURANCE HELD
Describe all life insurance policies held. Please be sure to include the face amount of the policies,
name of insurance company, beneficiaries and the cash surrender values of the policies.
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FINALLY, PLEASE BE SURE TO SIGN AND DATE THE PERSONAL
FINANCIAL STATEMENT, AND INDICATE YOUR SOCIAL SECURITY
NUMBER IN THE SPACE PROVIDED.