Personal Net Worth Statement
                  Name:
                  Date:
                  Is this Statement is Joint (i.e., Spouse or Life Partner):
             !!   Tip: Read Over All Categories Before Starting
                  PERSONAL ASSETS (Do Not Subtract Debt Balances)
                                                                      Description           Amount
                  A. Short-Term Liquid Assets (Cash, equivalent, or maturity in less than six months)
                       Cash on Hand
                       Checking Account
                       Savings Account
                       Cash Surrender Value of Life Insurance
                           Not Benefit Amount
                       Money Market Account
                       Other:
                       Other:
                       Other:
                       Other:
                       Other:
                  A. Total Short-Term Liquid Assets                                       $                          -   
                                                                      Description           Amount
                  B. Business Ownership Interests
                       Real Estate (Rental Property or Land); Not Primary Home
                           Do not adjust for debt amount for any asset
                       Sole Proprietorship
                       Partnership
                       Limited Liability Company
                       B or C Corporation
                       S Corporation
                       Other:
                       Other:
                       Other:
                       Other:
                       Other:
                  B. Total Business Ownership Interests                                   $                          -   
                                                       Page 1 of 4
                                                                  Description         Amount
                 C. Invested Assets (Current Market Value; Do Not Include Pension Payments)
                      Stocks
                      Bonds
                      Mutual Funds
                      CDs
                      IRA
                      401k
                      403b
                      Other Retirement Accounts
                      Other:
                      Other:
                      Other:
                      Other:
                      Other:
                 C. Total Invested Assets                                           $                          -   
                                                                  Description         Amount
                 D. Use Assets (Current Market Value)
                      Home Fair Market Value
                         Do not adjust for debt amount for any asset
                      Vacation Home or Time Share
                      Automobiles
                      Furnishings
                      Collectibles
                      Jewelry, Fur
                      Other Personal (Easily Removable) Property
                      Other:
                      Other:
                      Other:
                      Other:
                      Other:
                 D. Total Use Assets                                                $                          -   
                                                                  Description         Amount
                 E. Other
                      Notes Receivable
                      Other:
                      Other:
                      Other:
                      Other:
                      Other:
                 E. Total Other                                                     $                          -   
                 TOTAL ASSETS (A + B + C + D + E)                                    $                -   
                                                   Page 2 of 4
            PERSONAL LIABILITIES
                                                Description    Amount
            Notes Payable to Others
               Personal Loans
            Installment Account (Automobiles)
            Lease Obligations (Automobiles)
            Installment Account (Other)
            Lease Obligations (Other)
            Loan on Life Insurance
            Mortgages on Home Real Estate
            Mortgages (Home Equity Loan) on Home Real Estate
            Mortgages (Other) on Home Real Estate
            Mortgages on Investment Real Estate
            Past Due IRS
            Past Due State Tax
            Past Due Local Tax
            Past Due Other Tax
            Retirement Account Loans
            Credit or Store Card 1 (Exclude Balances Payable by Your Company)
            Credit or Store Card 2 (Exclude Balances Payable by Your Company)
            Credit or Store Card 3 (Exclude Balances Payable by Your Company)
            Credit or Store Card 4 (Exclude Balances Payable by Your Company)
            Credit or Store Card 5 (Exclude Balances Payable by Your Company)
            Credit or Store Card 6 (Exclude Balances Payable by Your Company)
            Credit or Store Card 7 (Exclude Balances Payable by Your Company)
            Credit or Store Card 8 (Exclude Balances Payable by Your Company)
            Credit or Store Card 9 (Exclude Balances Payable by Your Company)
            Credit or Store Card 10 (Exclude Balances Payable by Your Company)
            Credit or Store Card 11 (Exclude Balances Payable by Your Company)
            Student Loans
            Miscellaneous Accounts Payable
            Contracts
            Legal Claims (Amounts are Known)
            Judgments (Amounts are Known)
            Collection Accounts 1
            Collection Accounts 2
            Collection Accounts 3
            Collection Accounts 4
            Other:
            Other:
            Other:
            Other:
            Other:
                                      Page 3 of 4
               Other:
               Other:
               Other:
               Other:
               Contingent Liabilities ("Contingents")
                    Contingent Liabilities May Not Occur and/or
                       Contingent Liability Amounts Are Tentative
                          As Co-Signer/Co-Maker
                          As Endorser
                          As Guarantor
                          Legal Claims (Amount is Tentative)
                          Judgments (Amount is Tentative)
                          Other Contingent:
                          Other Contingent:
                          Other Contingent:
                          Other Contingent:
               Total Personal Liabilities                                   $                          -   
               TOTAL PERSONAL LIABILITIES WITHOUT CONTINGENTS               $                -   
               NET WORTH CALCULATION
               Total Assets                                                 $                    -   
               Total Liabilities (As a Negative Number) Without Contingents       0.00 
               NET WORTH (SUM) WITHOUT CONTINGENTS                          $                -   
                                              Page 4 of 4