Arizona > Workers Comp
Personal Financial Statement - Arizona
| Personal Financial Statement Form. This is a Arizona form and can be used in Workers Comp . |
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LABOR DEPARTMENT PERSONAL FINANCIAL STATEMENT Name Date Home Address (Number & Street (City) (State) (Zip) Assets Amount Liabilities AmountCash_______________________________________________ Notes Payable: _ Accounts Receivable-Good______________________________ Stocks & Bonds(Schedule B)_____________________________ Other Notes Payable: Notes Receivable- Good_________________________________ Cash Surrender Value Life Ins.___________________________ Autos:______________________________________________ Accounts _ Payable________________________________________ (Yr./Make) (Yr./Make) Taxes Payable___________________________________________ Real Estate (Schedule A)________________________________ other assets (describe): Contracts Payable________________________________________ 1._________________________________________________ __ To:__________________________________________________ To:__________________________________________________ 2._________________________________________________ __ Real Estate Indebtedness 3._________________________________________________ (Schedule A Other Liabilities): __ 1.___________________________________________________ 2.___________________________________________________ __ 3.___________________________________________________ __ Other Liabilities: TOTAL LIABILITES_____________________________________ NET WORTH___________________________________________ TOTAL ASSETS TOTAL_______________________________________________ _ ANNUAL INCOME ANNUAL EXPENDITURES (Excluding ordinary living expense ) Salary______________________________________________ Real Estate _ Payment(s)____________________________________ Salary (Wife or Rent_________________________________________________ Husband)________________________________ __ Securities Income Income______________________________________ Taxes___________________________________________ Rentals_____________________________________________ Insurance _ Premiums______________________________________ Other (describe) Property Taxes__________________________________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 21._________________________________________________ __ Other (describe, include installment payments 2._________________________________________________ other than Real Estate): __ 3._________________________________________________ 1.___________________________________________________ __ __ 4._________________________________________________ 2.___________________________________________________ __ __ TOTAL TOTAL EXPENDITURES_____________________ INCOME_____________________ Total Expenditures_____________________________________ NET CASH INCOME: (exclusive of ordinary living expenses) Page 1 of 2 What assets in this statement are in joint tenancy?_____________________ ___________________________________________________________________Name of other party Are you a guarantor on anyones debt? If so, give details: Are any encumbered assets or debts secured except as indicated? If so, please itemize by debt and security________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________Have you: (a) Ever been the subject of a voluntary or involuntary peti tion in bankruptcy?_____________________________________________________ ___ (b) Ever been adjudicated bankrupt?__________________ _______________________ Date___________________________________________ __ (c) Ever been an officer or a partner in any establis hment subject to a involuntary position in bankrupcty?__________________ _________________ (d) Ever been an officer or a partner in any establis hement adjudicated bankrrupt?___________________________________________ ___________Have you ever been convicted of misappropriating funds? Yes ________ N o___________ If yes, give details and dates:__________________________________________________________________ _______________________________________ SCHEDULE A - REAL ESTATE: Location and Type of Title Estimated Amount To Whom Real Estate in Name of Value Owing Payable $ $ SCHEDULE B - STOCKS AND BONDS: Number of Shares Description Current Market Value Estimate Value Amount of Bonds on Listed on Unlisted $ $ If additional space is needed for Schedule A and/or Schedule B, list on separate sheet and attach. INSURANCE: Life Insurance $ Name of Company Beneficiary Automobile Insurance: Public Liability: Yes No Property Damage: Yes No Comprehensive personal Liability: Yes No Note: It is a felony to knowingly file a false or forged instrument with a Public Office in this State (A.R.S. 39 -161).AFFIDAVIT: Under penalties of perjury, I declare and affirm that the st atement made in the foregoing financial statement, including any accompanying attachment (s) are true, complete and correct. Date Signature American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3NOTARIZATION: Subscribe and sworn to before me this day of 19 My commission expires on: * seal * Notary Public Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com
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