Financial Statement form

A financial statement form can be used to provide annual or monthly financial data.  This form can be used by lenders or other stakeholders to carry out a financial assessment of individuals. It gives a picture of an individual’s assets, liabilities and income; below is a sample financial statement form.

Sample financial statement form

Name: __________________________________________________________

Social security number: _____________________________________________

Date of birth: _____________________________________________________

Telephone: _______________________________________________________

E-mail: __________________________________________________________

Address: _________________________________________________________

Current financial information

Employer (Organization’s name) _________________________________

Address: ____________________________________________________

Telephone: __________________________________________________

Job title: ____________________________________________________

Name of supervisor: __________________________________________

Starting date: ________________________________________________

Monthly income

Source      Amount

____________________________     ______________________

_____________________________  ______________________

___________________________  _______________________

Total income    _______________________________

Expenses

Item       Amount

_______________________   _____________________

_______________________   _____________________

________________________  ______________________

_______________________   ______________________

Total expenses ____________________________

Total net income (after deducting expenses) __________________________

Assets and Liabilities

Item      Amount in  Amount out

______________________   ____________ ______________

______________________   ____________ _______________

______________________   _____________ _______________

Total assets _________________  total liabilities ____________________

Net worth ____________________________________

Category: Financial Forms