FINANCIAL STATEMENT (SAMPLE)
The following form is provided for informational purposes only and is intended to be used as a guide prior to consultation with an attorney familiar with your specific legal situation. This form is not a substitute for the advice of an attorney. If you require legal advice, you should seek the services of an attorney.

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