Sheet 1: Summary

	
	
	
	
	
	
	

		


		
NET WORTH SUMMARY
		
	

		


		


		


		


		


		


		


		


	
	

		


		
 Name 
		
	

		


		
 Position 
		
	

		


		
 Licensee Name 
		
	

		


		


		


		


		


		


		


		


	
	

		


		
Template Version: 2/13/2017
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
STATEMENT OF ASSETS
		


		


		


		


		


		


	
	

		


		
Please complete all detailed schedules/tabs listed for all of the assets, both tangible and intangible, held by you, your spouse and your dependent children on the appropriate schedule/tab as noted below.  Enter the amount as of the date of this Statement.  Only enter in the cells highlighted yellow on this tab.  All listed assets must be described fully on the appropriate schedule/tab attached.  The “totals” should transfer from the detailed schedule/tab to this summary page.   For the 'Previous Net Worth Summary' column, please enter the amounts from the last Net Worth Summary submitted and the date of that Net Worth Summary statement on this summary page.  Percentage changes will be automatically calculated.  Please explain any % change > +/- 10 % and $100,000 in the Comments Column.
		
	

		


		
	

		


		


		


		


		


		


		


		


	
	

		


		


		


		
 CURRENT 
		
 PREVIOUS 
		


		


		


	
	

		


		


		


		
 NET WORTH 
		
 NET WORTH 
		


		


		


	
	

		


		


		
TAB
		
 SUMMARY 
		
 SUMMARY 
		
 Difference 
		
% change
		
Comments
	
	

		


		


		


		
 Insert Date Here 
		
 Insert Date Here 
		


		


		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
Cash on Hand
		


		


		


		
 $- 
		
0.00%
		


	
	

		


		
Cash in Banks
		
A
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Accounts & Notes Receivable
		
B
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Stocks, Bonds, Notes & Debentures
		
C
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Business Investments
		
D
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Real estate
		
E
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Life Insurance
		
F
		
 $- 
		


		
 $- 
		
0.00%
		
 
	
	

		


		
Pension/Retirement Funds
		
G
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Vehicles
		
H
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Other Assets
		
I
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
TOTAL ASSETS
		


		
 $- 
		
 $- 
		
 $- 
		
0.00%
		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
STATEMENT OF LIABILITIES
		


		


		


		


		


		


	
	

		


		
Please complete all detailed schedules/tabs listed for  all of the liabilities held by you, your spouse and your dependent children on the appropriate schedule/tab as noted below.  Enter the amount as of the date of this Statement.  All listed liabilities must be described fully on the appropriate schedule/tab attached.  The “totals” should transfer from the detailed schedules/tab to this summary page.  Percentage changes will be automatically calculated.  Please explain any % change > +/- 10 % and $100,000 in the Comments Column.
		
	

		


		


		


		


		


		


		


		


	
	

		


		


		


		
 CURRENT 
		
 PREVIOUS 
		


		


		


	
	

		


		


		


		
 NET WORTH 
		
 NET WORTH 
		


		


		


	
	

		


		


		
TAB
		
 SUMMARY 
		
 SUMMARY 
		
 Difference 
		
% change
		
Comments
	
	

		


		


		


		


		


		


		


		


	
	

		


		
Accounts Payable
		
J
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Taxes Payable
		
K
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Notes and Loans Payable
		
L
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		
Mortgages / Liens Payable (Real Estate)
		
M
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
Other Liabilities
		
N
		
 $- 
		


		
 $- 
		
0.00%
		


	
	

		


		
TOTAL LIABILITIES
		


		
 $- 
		
 $- 
		
 $- 
		
0.00%
		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
NET WORTH
		


		
 $- 
		
 $- 
		
 $- 
		
0.00%
		
 
	
	

		


		


		


		


		


		


		


		


	
	

		


		
Contingent Liabilities
		
O
		
 $- 
		
   
		
 $- 
		
0.00%
		


	
	

		


		


		


		


		


		


		


		


	
	

		


		
Net Worth (inc. Contingent Liabilities)
		


		
 $- 
		
 $- 
		
 $- 
		
0.00%
		


	

 




Sheet 2: Sch. A

	
	
	
	
	
	
	

		
Schedule A - Cash in Banks
		


		
Name
		
	

		
Template Version: 2/13/2017
		


		


		


		


		


	
	

		
List all bank accounts, foreign and domestic, maintained by you, your spouse, and/or your dependent children.  Insert additional rows if needed.
		
	

		
	

		
	

		


		


		


		


		


		


	
	

		
Name and Address 
		
Whose account?
		
Account Number
		
Type of
		
Interest
		
 Current  
	
	

		
of Financial Institution
		
You/Spouse/Child
		
 (Last 4 Digits)
		
Account
		
Rate
		
 Balance 
	
	

		
 
		
 
		
 
		
 
		
 
		


	
	

		
 
		


		


		


		


		


	
	

		


		
 
		
 
		
 
		
 
		
   
	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		


		


	
	

		


		


		


		


		
TOTAL:
		
 $- 
	
	

		


		


		


		


		


		


	



Sheet 3: Sch. B

	
	
	
	
	
	
	
	

		
Schedule B - Accounts & Notes Receivable
		


		


		


		


		
Name
		
	

		
Template Version: 2/13/2017
		


		


		


		


		


		


		


		


	
	

		
List all accounts and notes receivable held by you, your spouse, and/or your dependent children.  Insert additional rows as needed.
		
	

		
	

		
	

		


		


		


		


		


		


		


		


		


	
	

		
Name and Address 
		
Whose account?
		
Date 
		
 Original  
		
 Unpaid  
		
Interest 
		
Maturity
		


		
Collateral Securing
	
	

		
of Debtor
		
You/Spouse/Child
		
Incurred
		
 Amount 
		
 Balance 
		
Rate
		
Date
		
Purpose
		
Account or Note
	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


	
	

		


		


		


		
 TOTAL: 
		
 $-