Financial Statement Short Form
A financial statement short form is a mini statement of the financial assets, liabilities, income and expenses of a person or an institution including profit and non-profit organizations. The financial statement short form should start with the personal details of the person or institution and then should be followed by a break-up of the financial details. The following sample financial statement short form is given below for your reference.
Sample Financial Statement Short Form
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Financial Statement
Short form
Personal Information
| Name: |
| Social Security Number: |
| Full address:
City: State: Zip Code: Country: |
| Telephone number: |
| Date of birth: |
| Occupation: |
| Employer: |
| Address of the employer: |
| Telephone number of the employer: |
| Do you have an insurance coverage? Yes / No
If ‘yes’, provide the name of the health insurance provider _____________________ |
Gross weekly income or receipts
| Base pay from:
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Type of job:
- Full time
- Part time
- Contract
- Freelancer
- Self-employment
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Tick the other sources of income:
- Commissions
- Dividends
- Interest
- Trusts
- Annuities
- Pension
- Retirement funds
- Rent from property
- Royalties and gifts
- Contribution from household members
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| Social security available: Yes / No
If ‘yes’, which of these is applicable to you?
- Disability
- Unemployment insurance
- Worker’s compensation
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| Is public assistance available? Yes / No
If ‘yes’, which of these is applicable to you?
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Weekly expenses
| Rent or mortgage: |
| Maintenance and repair: |
| Electricity: |
| Telephone: |
| House supplies: |
| Laundry and cleaning: |
| Medical expenses: |
| Insurance premium: |
Assets
| Property of real estate: |
| Motor vehicles: |
| Pension: |
| Life insurance: |
| Savings accounts: |
| Others (stocks, bonds, etc.): |
Liabilities
| Sl. No |
Creditor |
Nature of debt |
Date incurred |
Amount due |
Weekly payment |
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Category: Financial Forms
