Sample Financial Statement
Also available in PDF | MS Word
Before entering into a prenuptial or premarital agreement, each prospective spouse must make a complete and honest financial disclosure to the other. The following form, used in conjunction with the advice and counsel of your family law attorney, can be useful in putting together your own financial statement and verifying that the information you receive from your spouse is complete.
A. Gross Monthly Income Source/Amount ________________/$________ Source/Amount ________________/$________ Source/Amount ________________/$________ TOTAL: $________________ B. Deductions from Gross Income |
| State Income Tax | $____________________ |
| Federal Income Tax | $____________________ |
| Social Security | $____________________ |
| Self-employment Tax | $____________________ |
| Health Insurance | $____________________ |
| Union Dues | $____________________ |
| Pension/Retirement | $____________________ |
| Support Orders | $____________________ |
| Other | $____________________ |
| TOTAL : $_______________ C. NET MONTHLY INCOME: (gross income minus total deductions) $_______________ D. Assets & Liabilities |
| Value | Owe |
| Primary Home | $_______________ | $_______________ | |
| Vacation Home | $_______________ | $_______________ | |
| Other Home/Property | $_______________ | $_______________ | |
| Vehicle(s) | $_______________ | $_______________ | |
| Recreational Vehicle | $_______________ | $_______________ | |
| Boat(s) | $_______________ | $_______________ | |
| Furniture | $_______________ | $_______________ | |
| Home Furnishings | $_______________ | $_______________ | |
| Appliances | $_______________ | $_______________ | |
| Artwork | $_______________ | $_______________ | |
| Jewelry | $_______________ | $_______________ | |
| Computer(s) | $_______________ | $_______________ | |
| Personal Property | $_______________ | $_______________ | |
| Cash | $_______________ | $_______________ | |
| Stocks/Bonds/Funds | $_______________ | $_______________ | |
| Stock Options | $_______________ | $_______________ | |
| Checking Account(s) | $_______________ | $_______________ | |
| Savings Account(s) | $_______________ | $_______________ | |
| Retirement/Pensions | $_______________ | $_______________ | |
| Profit Sharing | $_______________ | $_______________ | |
| IRA(s) | $_______________ | $_______________ | |
| Business(es) | $_______________ | $_______________ | |
| Professional Practice | $_______________ | $_______________ | |
| Life Insurance | $_______________ | $_______________ | |
| Other Assets |
| Description | Value |
|
TOTAL ASSETS: $_______________ | TOTAL LIABILITIES: $_______________ |
E. NET WORTH: (assets minus liabilities) $___________________________ |
F. Educational Degrees
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