ASSETS AND LIABILITIES:
Summary of Net Worth. Please
estimate your total Net Worth (total value of all assets less
liabilities -- remember to also include any
retirement accounts or life insurance policies owned by you or your spouse):
Property in Your
Name:
$____________________ Property in Spouse’s Name: $______________________
Property in Joint Names:
$______________________
Please also provide a general description
and “ballpark” estimated values of your various assets (both in your name,
owned individually in your spouse’s name, if applicable, and held jointly by
both spouses, if applicable). Please also indicate any “major”
liabilities for which any of the assets serve as security, indicating the name
of the bank or financial institution to which the liability is owned, and the
name or names in which the liability was incurred:
Your Separate Properties:
__________________________________________________________________________________
__________________________________________________________________________________
Spouse’s Separate Properties:
__________________________________________________________________________________
_________________________________________________________________________________
Jointly-Held Properties:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
SPECIFIC ASSET INFORMATION:
Life Insurance:
1. Name of Company and Policy
Number:____________________________________________________
Owner:_________________________________
Insured:___________________________________
Face Amount: $ Current
Cash Surrender Value: $______________________
Primary
Beneficiary(ies):___________________________________________________________
Contingent
Beneficiary(ies):_________________________________________________________
Type Coverage (i.e., term,
whole life, universal life policy):________________________________
Premium Amount: $_____________ Premium Payment Schedule: Monthly,
Quarterly, Annually?
2. Name of Company and Policy
Number:___________________________________________________
Owner:_____________________________
Insured:_______________________________________
Face Amount: $ Current
Cash Surrender Value: $______________________
Primary
Beneficiary(ies):___________________________________________________________
Contingent
Beneficiary(ies):_________________________________________________________
Type Coverage (i.e., term,
whole life, universal life policy):_______________________________
Premium Amount: $_____________ Premium Payment Schedule: Monthly,
Quarterly, Annually?
3. Name of Company and Policy
Number:___________________________________________________
Owner:_____________________________
Insured:______________________________________
Face Amount: $ Current
Cash Surrender Value: $______________________
Primary
Beneficiary(ies):__________________________________________________________
Contingent
Beneficiary(ies):________________________________________________________
Type Coverage (i.e., term,
whole life, universal life policy):_______________________________
Premium Amount: $_____________ Premium Payment Schedule:
Monthly, Quarterly, Annually?
TOTAL INSURANCE on His Life
$______________________ on Her Life $_____________________
Please attach additional blank sheets or add
onto back of this sheet similar information for any other life insurance
policies that you, your spouse, or other family member may own.
