Financial Statement

Date: _________________________

Male Applicant Female Applicant

Name: ________________________________	Name: ________________________________
Occupation: ___________________________	Occupation: ____________________________
Employer: ____________________________	Employer: _____________________________
Business Address: _________________________ ______________________________________	Business Address: _________________________ ______________________________________
Business Phone: _______________________ Yearly Income: ___________________________ Other Income: ____________________________ Joint Asset and Assets – What I Own: Home (estimated market value) ______________ Total Savings & Checking ______________ Other Real Estate ______________ Stocks and Bonds ______________ Furniture & Appliances ______________ Automobiles & Trucks ______________ Travel Trailers, Motor Homes, Campers ______________ Boats, Motors, Motorcycles, Snowmobiles ______________ Valuables: Antiques, Coin Collections, Jewelry ______________ 401K/Retirement Accounts ______________ Other Assets (describe): ____________________ ______________ ____________________ ______________ Total of All I Own ______________ Misc. Information (Do not include in totals.) Life Insurance ______________	Business Phone: _______________________ Yearly Income: ___________________________ Other Income: ____________________________ Liability Information Liabilities – What I Owe Mortgage on My Home _________________ Other Real Estate Loans _________________ Balance on Secured Loans _________________ Balance on Unsecured Loans _________________ Balance on Credit Cards _________________ Medical Bills _________________ Other Liabilities (describe): _________________________ _________________ _________________________ _________________ Total of Liabilities _________________ All I Own Minus All I Owe Total of All I Own _________________ Total of Liabilities _________________ Total Net Worth _________________

How much do you want to borrow from A Child Waits Foundation? _____________________________________