SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of

January 1, 2015

DECLARANT:

ADDRESS:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real
Properties
DESCRIPTION

KIND

(e.g. lot, house and

lot, condominium, and
improvements)

(e.g.,
residential,
commercial,
industrial,
agricultural
and mixed
used)

ASSESSED
VALUE

CURRENT
FAIR
MARKET
VALUE

ACQUISITION
ACQUISITI
ON COST

LOCATION
YEAR

MODE

Subtotal:

b. Personal Properties

XXXX

DESCRIPTION
Cash in Bank

YEAR
ACQUIRED

ACQUISITION COST/AMOUNT

2015

xxxxxx

Subtotal:
TOTAL ASSETS (a+b):

#VALUE!

2.
LIABILITIES*
NATURE

NAME OF CREDITORS

OUTSTANDING BALANCE

TOTAL LIABILITIES:
NET WORTH: Total Assets less Total Liabilities =

I hereby certify that these are true and correct statements of my assets, liabilities, net worth.
Date:

(Signature of Declarant)

SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued
identification card.

(Person Administering Oath)