Requisition Supplies/Materials Form

Wealth Accumulation Statement
Name
Date

MonthDayYear
Date

Assets

	$
Cash on Hand and in Banks
Savings Accounts
IRA or Other Retirement Account
Accounts and Notes Receivable
Life Insurance-Cash Surrender Value Only (Complete Section 8)
Stocks and Bonds (Describe in Section 3)
Real Estate (Describe in Section 4)
Automobile-Present Value
Other Personal Property (Describe in Section 5)
Other Assets (Describe in Section 5)
TOTAL

Liabilities

	$
Accounts Payable
Notes Payable to Banks and Others (Describe in Section 2)
Installment Account (Auto)
Monthly Payments
Installment Account (Other)
Monthly Payments
Loan on Life Insurance
Mortgages on Real Estate (Describe in Section 4)
Unpaid Taxes (Describe in Section 6)
Other Liabilities (Describe in Section 7)
Total Liabilities
Net Worth
TOTAL

Section 1 - Income

	Source of Income
Salary
Net Investment Income
Real Estate Income
Other Income (Describe Below)

	Contingent Liabilities
As Endorser or Co-Maker
Legal Claims & Judgments
Provisions for Federal Income Tax
Other Special Debt

Description of Other Income in Section 1:

Section 2 - Notes Payable to Banks and Others

	Name and Address of Note Holder(s)	Original Balance	Current Balance	Payment Amount	Frequency (Monthly, etc.)	How Secured or Endorsed Type of Collateral
1
2
3
4

Section 3 - Stocks and Bonds

	Number of Shares	Name of Securities	Cost	Market Value Quotation/Exchange	Date of Quotation/Exchange	Total Value
1
2
3
4

Section 4 - Real Estate Owned

Use each parcel separatley

	Property A	Property B	Property C
Type of property
Address
Date purchased
Original cost
Present market value
Name and address of mortgage holder
Mortgage account number
Mortgage balance
Amount of payment per month/year
Status of mortgage

Section 5 - Other Personal Property and Other Assets
(Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 6 - Unpaid Taxes
(Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attached)
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Section 7 - Other Liabilities
(Describe in detail)

Section 8 - Life Insurance Held
(Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)
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