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Confidential – Financial Statement
Name:______________________________________________
Phone:_____________________________________________
Street Address:______________________________________
City:_______________________________________________
State:______________ Zip Code:_______________________
Assets
Cash on Hand in Banks:_________________________
U.S. Government Securities:______________________
Accounts and Loans Receivable:___________________
Cash Value of Life Insurance:______________________
Value of Businesses Owned:______________________
Other Stocks and Bonds:_________________________
Real Estate:____________________________________
Other:_________________________________________
Total Assets:$__________________________________
Liabilities
Notes Payable:_________________________________
Liens on Real Estate:____________________________
Other Liabilities:________________________________
Total Liabilities:$____________________________
Net Worth (total assets minus total liabilities)
$_________________________________________
Source of Income:
Salary:___________________________________
Dividends and Interest:______________________
Bonus and Commissions:____________________
Real Estate Income:________________________
Other Income:_____________________________
Total Income:$__________________________
It is understood that this information will be held in strict confidence by Florida Business Advisors, its staff and officers. The undersigned certifies that this information is true and correct.
Signature: ___________________________________
Date: ____________________
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