Personal Financial Statement Sample

A personal financial statement form is a report that outlines the financial status (income and expenses) of a business or individual.

This includes noting your monthly income and expenses as well as your net worth. Organizing your information this way can also help you prepare for a mortgage application or arrange for private financing.


A financial or income statement is used to provide insight into a company’s assets and debts.

The average individual does not typically have a use for income statements. However, sole proprietors may use them in the same manner as other businesses.

High-net-worth individuals may also use financial statements for the purpose of participating in investment deals, obtaining loans, and developing tax, financial, and business plans. In some cases, personal financial statements may be used when running for a government office.

A personal financial/income statement can also be used to help with a marital settlement agreement. And accompanying hardship letters, bank loan applications, proof of income documents, proof of hardship, or just as an income statement.

Below is a monthly personal financial statement balance sheet or budget form to help you track your net worth from month to month.


FINANCIAL STATEMENT OF .............................................(Your Full Name)

EMPLOYMENT:

Occupation:..............................................................$..........................
Employed by:.............................................................$..........................
Employer's Address:....................................................$..........................
Pay Period:................................................................$..........................
Rate of Pay:..............................................................$..........................
Next Payday:.............................................................$..........................

AVERAGE MONTHLY INCOME:

Gross Salary or Wages (Monthly)....................................$..........................
Minus Social Security....................................................$..........................
Minus Income Taxes.....................................................$..........................

Other deduction from paycheck (monthly)
Insurance...................................................................$..........................
Credit Union................................................................$..........................
Union dues..................................................................$..........................
Other........................................................................$..........................

Net monthly salary or wages..........................................$..........................
Monthly income from other sources:................................$..........................
Bonuses, Commissions, etc:...........................................$..........................
Business income:.........................................................$..........................
Royalties, rents, etc:....................................................$..........................
Welfare, Unemployment, etc:.........................................$..........................
Other........................................................................$..........................

TOTAL Average Income (Monthly)...................................$..........................

AVERAGE MONTHLY EXPENSES

Prescriptions, Medical, Dental:.......................................$..........................
Rental or Mortgage Payment:........................................$..........................
Homeowner's insurance:...............................................$..........................
Property taxes:..........................................................$..........................
Electricity:................................................................$..........................
Water, sewer, garbage:...............................................$..........................
Natural gas, fuel oil:....................................................$..........................
Laundry, cleaning services:...........................................$..........................
Repairs and maintenance:.............................................$..........................
Pest control:..............................................................$..........................
Housewares:..............................................................$..........................
Clothing:...................................................................$..........................
Gifts, donations:.........................................................$..........................
Vacation expenses:.....................................................$..........................
Telephone (land line):..................................................$..........................
Cellular Phone:...........................................................$..........................
Cable TV:..................................................................$..........................
Entertainment:...........................................................$..........................
Food and grocery items:..............................................$..........................
Dining out:................................................................$..........................
Education:................................................................$..........................
Baby sitter, day care:.................................................$..........................
Public transportation:..................................................$..........................

Automobile:

Payments...................................................................$..........................
Insurance...................................................................$..........................
Gasoline, oil................................................................$..........................
Repairs......................................................................$..........................
License......................................................................$..........................

Insurance:

Health.......................................................................$..........................
Life...........................................................................$..........................
Disability....................................................................$..........................
Other........................................................................$..........................

FIXED DEBT (Monthly Basis)

Creditor 1...........................................monthly payment $........................
Creditor 2...........................................monthly payment $........................
Creditor 3...........................................monthly payment $........................
Creditor 4...........................................monthly payment $........................
Creditor 5...........................................monthly payment $........................
Creditor 6...........................................monthly payment $........................

Other Debt:

Creditor 1...........................................monthly payment $........................
Creditor 2...........................................monthly payment $........................
Creditor 3...........................................monthly payment $........................
Creditor 4...........................................monthly payment $........................

TOTAL Average Expenses (Monthly)................................$..........................

ASSETS:

Cash.........................................................................$..........................
Savings.....................................................................$..........................
Automobiles...............................................................$..........................
Real Estate................................................................$..........................
Stocks......................................................................$..........................
Bonds.......................................................................$..........................
IRA or Other Retirement Account...................................$..........................
401K........................................................................$..........................
Jewelry.....................................................................$..........................
Contents of Apartment or House....................................$..........................
Other.......................................................................$..........................
Other.......................................................................$..........................
Other.......................................................................$..........................

Total Assets..............................................................$..........................

LIABILITIES

Creditor 1 ..............................................Balance Due: $.........................
Creditor 1 ..............................................Balance Due: $.........................
Creditor 1 ..............................................Balance Due: $.........................
Creditor 1 ..............................................Balance Due: $.........................
Creditor 1 ..............................................Balance Due: $.........................

Total Liabilities...........................................................$..........................

SUMARY OF INCOME AND EXPENSES

Average monthly income..............................................$..........................
Average monthly expenses...........................................$..........................

SUMMARY OF ASSETS AND LIABILITIES

Total Assets:.............................................................$..........................
Total Liabilities...........................................................$..........................

Dated this..................... day of.........................., 20...........
State of...........................County of...............................

...................................................................
(Signature)

On this date, .................................... (full name of the declarer), who is personally known to me to be the person whose name is subscribed to the foregoing document, appeared before me, and, being duly sworn, verified the information contained in the foregoing document to be true and correct to the best of his/her knowledge and acknowledged that said document was signed as a free and voluntary act.

Subscribed and sworn to before me this............ day of ...................., 20.....

.......................................................
(Signature of Notary Public)

Notary Public for the County of .......................
State of............................
My commission expires........................


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