State Farm Personal Financial Statement – Fill Out and Use

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Instructions

Personal Financial Statement Instructions

Note: Start with completing the Schedules irst. he totals will carry forward to the Statement. Ater completing ALL applicable sections of the Schedules, please make sure all sections of the Statement are also completed as well.

Schedules

Complete each item as thoroughly as possible and provide all pertinent information requested.

Assets

Assets are things you own that are of monetary value.

·Complete Schedules (1-5) irst, totals will pull forward automatically to Statement.

·Include dollar value/present market value for all items listed as assets.

·“Other Assets” includes anything of monetary value not previously addressed.

·On the Statement, include cash surrender value of life insurance.

·On the Statement, list the number of automobiles owned and the total value of all automobiles.

·On the Statement, include amounts due from others.

·“Total Assets” will calculate automatically.

Liabilities

Liabilities are monies you owe to others.

·Complete Schedules (6-9) irst, totals will pull forward automatically to Statement.

·List outstanding balances on each line item.

·“Other Liabilities” includes any monies you owe to others not previously addressed.

·On Schedule 4, include your mortgage due on real estate/residence.

·On the Statement, include your real estate taxes due.

·On the Statement, include any rents and interest due.

·On the Statement, include any other accounts and notes payable to others.

·“Total Liabilities” will calculate automatically.

Total Net Worth

Total Net Worth is found by subtracting your liabilities from your assets. his will calculate automatically.

This is proprietary information owned by State Farm® and it may be lawfully used only as authorized by appropriate Agency management. 01-04-2011

Z-25204

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Schedules

No. 1 Checking & Savings Accounts (A list of all household checking and savings accounts)

Name and Location	Cash Balance
Checking:	$
	$
Savings:	$
	$
Total:	$

No. 2 Stocks and Bonds

Description of	Registered in	Cost	Present	Income Rec’d	If Pledged State
Security	Name of		Market Value	Last Year	to Whom
		$	$	$
		$	$	$
		$	$	$
		$	$	$
		$	$	$
	Total:	$	$	$

No. 3 S&T Plan, 401(k), Keogh, etc.

Registered in Name Of	Present Market Value
	$
	$
	$
	$
	$
Total:	$

No. 4 Real Estate (Solely or partially owned. If partially owned, provide dollar amounts based on percentage owned.)

Address / Description	Purchase		Purchase	Mortgages	Present	Payment
	Date		Price	or Liens	Market Value	Amount
		$		$	$	$
		$		$	$	$
		$		$	$	$
		$		$	$	$
		$		$	$	$
Total:		$		$	$	$

This is proprietary information owned by State Farm® and it may be lawfully used only as authorized by appropriate Agency management. 01-04-2011

Z-25204

statefarm.com/agents/career

Schedules

No. 5 Other Assets (excluding Auto(s))

Description

Cash Value

$

$

$

$

$

Total: $

No. 6 Credit Card Balance (Credit Cards in your or your spouse’s name)

Credit Card Name	Credit	Current	Monthly
	limit	Balance	Payment
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
	$	$	$
Total:	$	$	$

No. 7 Notes Payable to Banks (excluding real estate/mortgages) (A list of the amounts owed.)

Owed to Whom	Original	Balance	How	Description of Security
	Amount	Due	Long?	Held
	$	$
	$	$
	$	$
	$	$
	$	$
	$	$
	$	$
	$	$
	$	$
	$	$
Total:	$	$

This is proprietary information owned by State Farm® and it may be lawfully used only as authorized by appropriate Agency management. 01-04-2011

Z-25204

statefarm.com/agents/career

Schedules

No. 8 Other Liabilities

Description

Cash Value

$

$

$

$

$

Total: $

Completion and submission of this form certiies that the information provided has been carefully reviewed and is true and correct.

This is proprietary information owned by State Farm® and it may be lawfully used only as authorized by appropriate Agency management. 01-04-2011

Z-25204

statefarm.com/agents/career

Personal Financial Statement

Name

To: State Farm Insurance Companies

Address

City

State

Zip

Telephone

Date

Have you or your spouse (if married) ever defaulted on any loan? Y/N

Explain

Do you have an existing interest in any business? Y/N

Explain

Do you have an existing managerial role in any business? Y/N

Explain

Are you or your spouse (if married) the endorser or co-maker of any loans? Y/N

Explain

Are you responsible for any other debt not listed? Y/N

Explain

Assets			Liabilities $ Net Worth
Savings & Checking Accounts (Schedule No. 1)		$	Mortgage on Real Estate (Schedule No. 4)	$
Cash Surrender Value of Life Insurance		$	Real Estate Taxes Due	$
Stocks & Bonds (Schedule No. 2)		$	Rents & Interest Due	$
S&T Plan, 401(k), Keogh, etc. (Schedule No. 3)		$	Credit Card Balance (Schedule No. 6)	$
Real Estate (Schedule No. 4)		$	Notes Payable to Banks (Schedule No. 7)	$
Automobiles – Number/Market Value		$	Accounts & Notes Payable to Others	$
Amounts Due from Others		$	Other Liabilities (Schedule No. 8)	$
Other Assets (Schedule No. 5)		$
Total Assets:		$	Total Liabilities:	$
			Total Net Worth:	$

This is proprietary information owned by State Farm® and it may be lawfully used only as authorized by appropriate Agency management. 01-04-2011

Z-25204