Statement of Assets and Liabilities

Statement of

As at

ASSETS AND LIABILITIES

Assets
Fixed Property (Registered in my name) Plot no District Purchased price
Rand value

Liabilities
Bonds Bank AMT Outstanding and/or amounts owing under deeds of sale

Rand value

Machinery, plant, etc: (Specify important items only)

With whom

Vehicles, implements: (specify important items only)

Owing

To Whom

Instalments payable

Furniture and fittings: Other Assets

Investments: (Private co.shares/loans, etc)

Loans (Including insurance companies) To whom due Interest rate When repayable Amount

Loans (Including insurance companies)

To whom due Amounts Interest rate When repayable

Life policies:(Payable to the undersigned and not to any third party) Company Maturity date Amount Surrender value less loans: Other liabilities (Specify):

Shares: Number held Stock in trade: Book debts:

Company

Market Place: Surplus (Balance in my favour): Specify here contingent liabilities as guarantor, surety or otherwise

Bills receivable (not discounted) Bank balances (Specify) Cash: Goodwill and other assets: (Specify) Note: state if any assets are encumbered: Net annual emoluments form I/We hereby declare that this is a full, true and correct statement of my/our financial position and that my/our assets are not encumbered

Date: Signature

on

Income and Expenditure Monthly Income

Salary Maintenance Rent Investment Other

Total Income Montly Expenditure

Taxation Pension UIF Medical Aid Rent / Bond repayments Hire purchase instalments Lease agreements Credit card accounts Insurance premiums Transport Childrens clothing / education Loan repayments Donations Entertainment Budgeted savings Alimony / maintenance Electricity and water Rates and taxes Transport (petrol, bus fare, etc.) Groceries Telephone account Doctor / Chemist Maid / Gardener Security system TV rental / M-Net Other Other

Total Expenditure Surplus available for bank loan repayment