Before you begin
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This form runs entirely in your web browser. Nothing you type is sent anywhere automatically. As you work, a draft is kept only on this device, in this browser, so an accidental refresh will not lose your entries. When you are finished, use Print / Save as PDF to keep a copy and deliver the completed statement to the firm. For your protection, any unfinished draft is deleted from this device automatically 30 days after your last edit.
Please leave out account numbers. Institution names and balances are all the firm needs; "Chase checking" or "Fidelity brokerage" is plenty. Do not enter account numbers, online banking credentials, or Social Security numbers anywhere on this form.
Confidential
Personal Financial Statement
Boland Law Group, PLLC
This form runs entirely in your web browser. Nothing you type is sent anywhere automatically. As you work, a draft is kept only on this device, in this browser, so an accidental refresh will not lose your entries. When you are finished, use Print / Save as PDF to keep a copy and deliver the completed statement to the firm. Please leave out account numbers, online credentials, and Social Security numbers; institution names and balances are all the firm needs. Unfinished drafts are deleted from this device automatically 30 days after your last edit.
We do not collect Social Security numbers on this form or by email. If one is needed after you engage the firm, we will collect it in person or by telephone.
Assets
Non-Qualified (Taxable) Assets held outside retirement accounts
Cash on Hand & in Banks
$
Cash Value of Life Insurance
$
U.S. Government Securities
$
Other Marketable Securities
$
Notes & Accounts Receivable - Good
$
Notes & Accounts Receivable - Doubtful
$
Notes Due from Relatives & Friends
$
Other Securities - Not Readily Marketable
$
$
Subtotal · Non-Qualified Assets$0.00
Qualified / Tax-Deferred Accounts pass by beneficiary designation
Traditional IRA / SEP / SIMPLE
$
Roth IRA
$
401(k) / 403(b) / 457 Plans
$
Pension (Lump-Sum Value)
$
Annuities (Contract Value)
$
Health Savings Account (HSA)
$
$
Subtotal · Qualified Accounts$0.00
Real Estate, Business & Personal
Real Estate Owned (Market Value)
$
Mortgages & Contracts Owned
$
Business Interests (Est. Fair Market Value)
$
Personal Property
$
Digital Assets & Cryptocurrency
$
$
Subtotal · Real Estate, Business & Personal$0.00
Total Assets$0.00
Liabilities
Current Liabilities due within 1 year
Notes Due to Banks
$
Notes Due to Relatives & Friends
$
Notes Due to Others
$
Accounts & Bills Payable
$
Unpaid Income Taxes Due - Federal/State
$
Other Unpaid Taxes & Interest
$
Loans on Life Insurance Policies
$
Contract Accounts Payable
$
Cash Rent Owed
$
$
$
Total Current Liabilities$0.00
Long-Term Liabilities
Real Estate Mortgages Payable
$
Liens & Assessments Payable
$
$
$
Total Liabilities$0.00
Net Worth (Total Assets − Total Liabilities)$0.00
Total Liabilities & Net Worth$0.00
Annual Income
Salary, Bonuses & Commissions
$
Dividends & Interest
$
Rental & Lease Income (Net)
$
Social Security & Retirement Distributions
$
$
Spouse or Partner Salary, Bonuses & Commissions
$
$
Total$0.00
Estimate of Annual Expenses
Income Taxes
$
Other Taxes
$
Insurance Premiums
$
Mortgage Payments
$
Rent Payable
$
Other Expenses
$
Total$0.00
General Information
Are any Assets Pledged as collateral?
Are you a Defendant in any Suits or Legal Actions?
Have you been declared Bankrupt in the last 10 years?
Contingent Liabilities
As Endorser, Co-maker or Guarantor
$
On Leases or Contracts
$
Legal Claims
$
Federal - State Income Taxes
$
$
Total Contingent$0.00
Total Assets$0.00
Total Liabilities$0.00
Net Worth$0.00
All Section I entries agree with their supporting schedules.
I/We furnish the foregoing as a true and accurate statement of my/our financial condition. Authorization is hereby
given to Boland Law Group, PLLC, or their designees, to verify in any manner it deems appropriate any and all items
indicated on this statement.
Signature
Signature
Date