Statement of Assets and Liabilities
(as of _______________)
Assets
	Date of Purchase	Account Number	Current Market	Value
		(if relevant)
Cash and Cash Equivalents
Cash	_______________	_______________	$_______________
Checking accounts	_______________	_______________	$_______________
Savings accounts	_______________	_______________	$_______________
Money market accounts	_______________	_______________	$_______________
Other	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Real Estate
House/condo/coop	_______________	_______________	$_______________
Vacation	_______________	_______________	$_______________
Income properties	_______________	_______________	$_______________
Unimproved lot	_______________	_______________	$_______________
Other lot	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Personal Property
Motor vehicles	_______________	_______________	$_______________
Furniture	_______________	_______________	$_______________
Home furnishings	_______________	_______________	$_______________
Electronic equipment	_______________	_______________	$_______________
Computer system	_______________	_______________	$_______________
Jewelry	_______________	_______________	$_______________
Clothing	_______________	_______________	$_______________
Collections (coin, stamp)	_______________	_______________	$_______________
Animals	_______________	_______________	$_______________
Other	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Investments
Life ins. (term cash value)	_____________	_______________	$_______________
Life ins. (whole policies)	_______________	_______________	$_______________
Stocks	_______________	_______________	$_______________
Bonds	_______________	_______________	$_______________
Mutual funds	_______________	_______________	$_______________
Annuities	_______________	_______________	$_______________
IRAs	_______________	_______________	$_______________
Keoghs	_______________	_______________	$_______________
401k Plans	_______________	_______________	$_______________
Other retirement plans	_______________	_______________	$_______________
Partnerships	_______________	_______________	$_______________
Accounts receivable	_______________	_______________	$_______________
Other	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Liabilities
	Date Incurred	Account Number	Total Balance Due
Secured
Mortgage	_______________	_______________	$_______________
Mortgage	_______________	_______________	$_______________
Deeds of trust	_______________	_______________	$_______________
Home equity loans	_______________	_______________	$_______________
Liens	_______________	_______________	$_______________
Motor vehicle loans	_______________	_______________	$_______________
Bank loans	_______________	_______________	$_______________
Personal loans	_______________	_______________	$_______________
Other	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Unsecured
Student loans	_______________	_______________	$_______________
Bank loans	_______________	_______________	$_______________
Personal loans	_______________	_______________	$_______________
Credit card balances	_______________	_______________	$_______________
Judgments	_______________	_______________	$_______________
Taxes	_______________	_______________	$_______________
Support arrears	_______________	_______________	$_______________
Other	_______________	_______________	$_______________
Subtotal	_______________	_______________	$_______________

Net Worth Summary

Total Assets
Cash Subtotal	$_______________
Real Estate Subtotal	$_______________
Personal Property Subtotal	$_______________
Investments Subtotal	$_______________

Total Assets		$_______________

Total Liabilities
Secured Subtotal	$_______________
Unsecured Subtotal	$_______________
Total Liabilities		$_______________

Net Worth
(Assets minus liabilities)		$_______________