NET WORTH STATEMENT

Client Spouse Joint Total

ASSETS
Liquid Assets
Cash and Chequing Accounts __________ __________ __________ __________
Savings Accounts __________ __________ __________ __________
Credit Union __________ __________ __________ __________
Money Market Funds __________ __________ __________ __________
Other __________ __________ __________ __________
Total Liquid Assets __________ __________ __________ __________

Investment – Short Term

Term Deposits __________ __________ __________ __________
Treasury Bills __________ __________ __________ __________
Cash Value – Life Insurance __________ __________ __________ __________
Other __________ __________ __________ __________
Total Investment – Short Term __________ __________ __________ __________

Investment – Equity
Common/Preferred Stock __________ __________ __________ __________
Mutual Funds __________ __________ __________ __________
RRSP __________ __________ __________ __________
Pension/Profit Sharing Plan __________ __________ __________ __________
Income Trusts __________ __________ __________ __________
Other __________ __________ __________ __________
Total Investment – Equity __________ __________ __________ __________

Investment – Fixed Income

GICs – Long Term __________ __________ __________ __________
Corporate/Government Bonds __________ __________ __________ __________
RRSP __________ __________ __________ __________
Pension/Profit Sharing Plan __________ __________ __________ __________
Other __________ __________ __________ __________
Total Investment – Fixed Income __________ __________ __________ __________

Investment – Miscellaneous
Limited Partnership __________ __________ __________ __________
Tangible Assets __________ __________ __________ __________
Business Ownership __________ __________ __________ __________
Real Estate (excluding residential) __________ __________ __________ __________
Other __________ __________ __________ __________
Total Investment – Miscellaneous __________ __________ __________ __________

1
NET WORTH STATEMENT – Cont’d

Client Spouse Joint Total

Personal Assets
Residence/Vacation Home __________ __________ __________ __________
Automobiles __________ __________ __________ __________
Personal Property __________ __________ __________ __________
Other __________ __________ __________ __________
Total Personal Assets __________ __________ __________ __________
TOTAL ASSETS __________ __________ __________ __________

LIABILITIES
Short Term
Current Bills __________ __________ __________ __________
Credit Cards __________ __________ __________ __________
Installment Loans __________ __________ __________ __________
Other __________ __________ __________ __________
Total Short Term __________ __________ __________ __________

Long Term
Mortgage __________ __________ __________ __________
Life Insurance Loans __________ __________ __________ __________
Borrowing from RRSPs/Employer __________ __________ __________ __________
Loans to Purchase Investment __________ __________ __________ __________
Other __________ __________ __________ __________
Total Long Term __________ __________ __________ __________

TOTAL LIABILITIES __________ __________ __________ __________

Total Assets __________ __________ __________ __________

Total Liabilities __________ __________ __________ __________

Total Net Worth __________ __________ __________ __________