FINANCIAL STATEMENT Please fill out the following financial information for our records. most of the fields require an entry/number, even if the answer is zero! Name Applicant 1 * First Name Last Name Name Applicant 2 First Name Last Name Have you ever filed bankruptcy? * Yes No If yes, what year? ASSETS- THIS IS WHAT I/WE OWN Home-Primary Residence * $ Other Real Estate * $ Checking Balance * $ Savings Balance * $ Stocks & Bonds * $ 401k/Retirement Accounts * $ Furniture/Appliances * $ Automobiles/Trucks * $ RV/Trailer/Boat/Motorcycle * $ Jewelry + Any Other Valuables * $ Other * $ LIABILITIES - THIS IS WHAT I/WE OWE Mortgage Balance * $ Other Real Estate Balance(s) * $ Automobile Loan(s) * $ Outstanding Credit Card(s) * $ Balance on Student Loan(s) * $ Taxes or Assessments * $ Medical Bills * $ Other Liabilities * $ Any Other Debt/Loan $ FAMILY BUDGET-MONTHLY EXPENSES Mortgage/Rent * $ Other Real Estate * $ Auto Insurance * $ Life Insurance * $ Medical Insurance * $ Charge Accounts * $ Car Loan Payment(s) * $ Other Loans * $ Food * $ Utilities * $ Internet/Phone/Cable/Cell * $ Childcare and/or Education * $ Entertainment * $ Donation/Contributions * $ Household Maintenance * $ Non-food Items * $ Gas/Auto Maintenance * $ Clothing * $ Money to Savings * $ Pet Expenses * $ Gym or any other monthly membership * $ Other * $ Total of all Monthly Expenses * $ Money Left after ALL Monthly Expenses Paid * $ How do you intend to pay any fees associated with your adoption? Checkbox * Mark this box if Applicant 1 believes the financial statement above to be true and correct. Mark this box if Applicant 2 believes the financial statement above to be true and correct. Date Completed * MM DD YYYY Thank you! This will be uploaded to your secure Google Drive file.
