Consumer Debtor Financial Statement 

Note: Complete all blocks, except shaded areas. Write “N/A” (not applicable) in those blocks that do not apply. 

1 Debtor(s) name(s) and address 2 Home phone number 3 Marital status 

4a Debtor’s social security number 4b Spouse’s social security number 

Section I Employment Information a How long employed b Business phone number 

( ) 

c Occupation 

e Pay period: 

 Γ Weekly Γ Bi-weekly 

 Γ Monthly Γ .............. 

5 Debtor employer or business (name and address)

d Number of exemptions 

 claimed on Form W-4 

Payday......................(Mon-Sun) 

f (Check appropriate box)

Γ Wage earner 

Γ Sole proprietor 

Γ Partner 

a How long employed b Business phone number 

( ) 

c Occupation 

e Pay period: 

 Γ Weekly Γ Bi-weekly 

 Γ Monthly Γ .............. 

6 Spouse’s employer or business (name and address)

d Number of exemptions 

 claimed on Form W-4 

Payday......................(Mon-Sun) 

f (Check appropriate box)

Γ Wage earner 

Γ Sole proprietor 

Γ Partner 

Section II Personal Information 

7 Name, address and telephone number of next of kin or 

other relative 

8 Other names or alias 9 Previous address(es) 

10 Age and relationship of dependents living in your household (exclude yourself and spouse)

Section III General Financial Information 

11 Bank accounts (include savings and loans, credit unions, IRA and retirement plans, certificates of deposit, etc.) Enter bank loans in item 27. 

Name of Institution Address Type of Account Account No. Balance 

Total (Enter in item 20)............................................................................................................................. ►

12 Charge card lines of credit from banks, credit unions, and savings and loans. List all other charge accounts in item 27. 

Type of Account 

or Card 

Name and Address 

of Financial Institution

Monthly 

Payment

Credit 

Limit 

Amount 

Owed 

Credit 

Available 
Totals (Enter in item 26) ►

Section III (continued) General Financial Information 

13 Safe deposit boxes rented or accessed (List all locations, box numbers, and contents)

14 Real Property (Brief description and type of ownership) Physical Address 

a

County ....................... 

b

County ....................... 

c

County ....................... 

15 Life Insurance (Name of Company) Policy Number Type Face Amount Available Loan Value 

Γ Whole 

Γ Term 

Γ Whole 

Γ Term 

Γ Whole 

Γ Term 

Total (Enter in item 22) ►

16 Securities (stocks, bonds, mutual funds, money market funds, government securities, etc.): 

Kind Quantity or 

Denomination 

Current 

Value 

Where 

Located 

Owner 

of Record 

17 Other information relating to your financial condition. If you check the “Yes” box, please give dates and explain on page 4, Additional Information or Comments: 

a Court proceedings Γ Yes Γ No | b Bankruptcies Γ Yes Γ No 

 

c Repossessions Γ Yes Γ No | d Recent sale or other transfer of assets less than full value Γ Yes Γ No

 

e Anticipated increase in income Γ Yes Γ No | f Participant or beneficiary to trusts, estate, profit sharing, etc. Γ Yes Γ No

18 Taxes 

a Did you file a Federal Income Tax Return last year? _________ Yes _________ No 

 Joint _________ Individual __________ Amount of Gross Income on return was _____________________ 

b Are you or did you receive a tax refund from Federal, State, City or County? ________ Yes ________ No If yes, list from whom and amount of each refund:

 Entity: _______________________________________________________________________________ $ _____________________________ 

 Entity: _______________________________________________________________________________ $ _____________________________ 

c Do you owe delinquent taxes? ________ Yes __________ No If yes, list below years and amounts due: 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 

 ___________________________________________________________________________________________________________ 
Section IV Assets and Liabilities 

Description 

Current 

Market 

Value 

Current 

Amount 

Owed 

Equity 

In 

Asset 

Amount 

of 

Monthly 

Payment 

Name and Address of 

Lien/Note Holder/Lender

Date 

Pledged 

Date of 

Final 

Payment 

19 Cash 

20 Bank Accounts (from item 11) 

21 Securities (from item 16) 

22 Cash or loan value of insurance 

23 Vehicles (model, year, license, tag #) 

 a 

 b 

 c 

a 

b 

24 Real 

Property 

 (from 

 Section III, 

 Item 14) c 

25 Other assets 

 a 

 b 

 c 

 d 

 e 

26 Bank revolving credit (from item 12)

a 

b 

c 

d 

e 

f 

27 Other 

Liabilities 

 (including 

 bank loans, 

 judgements, 

 notes, and 

 charge 

 accounts 

 not entered 

 in item 11) 

g 

28 Federal taxes owed (prior years) 

29 Totals $ $ 
Section V Monthly Income and Expenses 

Total Income Monthly Expenses 

Source Gross Claimed 

30 Gross wages/salaries (debtor) $ 41 Rent/mortgage $ 

31 Gross wages/salaries (spouse) 42 Child support 

32 Interest, dividends 43 Alimony 

33 Net business income 44 Car payment 

34 Rental income 45 Gasoline/auto repairs 

35 Pension (debtor) 46 Electricity 

36 Pension (spouse) 47 Natural gas 

37 Child support 48 Food 

38 Alimony 49 Cable/satellite TV 

39 Other 50 Medical expenses (out-of-pocket) 

51 Clothing 

52 Trash 

53 Other 

40 Total income $ 54 Total expenses $ 

55 (Treasury use only) Net difference 

(income less necessary living expenses) 

$ 

Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other information is 

true, correct, and complete. 

56 Debtor’s signature 57 Spouse’s signature (if applicable) 58 Date