Form 440-5370 "Personal Balance Sheet" - Oregon

What Is Form 440-5370?

This is a legal form that was released by the Oregon Department of Consumer and Business Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Oregon Department of Consumer and Business Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 440-5370 by clicking the link below or browse more documents and templates provided by the Oregon Department of Consumer and Business Services.

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Download Form 440-5370 "Personal Balance Sheet" - Oregon

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Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
dfr.oregon.gov
Licensee name:
CRD/NMLS number:
Personal Balance Sheet
Cost
Method of valuation used (use same method for all assets):
Market Value
Asset
Value
Liabilities
Balance
Cash
Real Property
1. Checking account ...............................................
22. Primary residence mortgage .................
2. Savings account ..................................................
23. Home equity line of credit (HELOC) ..
3. Other (specify)
.........................................
24. Other residence mortgages ..................
25. Rental/investment property
Investments
26. Other (specify)
...........................
4. Stocks
................................................................
*
5. Bonds
.................................................................
Loans
6. Certificates of Deposit (CDs) ............................
27. Vehicle loans .......................................
7. Mutual funds .......................................................
28. Credit card debt ....................................
8. Other (specify)
.........................................
29. Personal loans ......................................
Retirement
30. Student loans .......................................
9. 401(k) or 403(b) ................................................
31. Other (specify)
...........................
10. Individual retirement accounts (IRAs) ............
Liens/Judgments/Compromises/Etc.
*
11. Keogh (vested interest) ....................................
32. Compromise with creditors
.................
*
12. Life insurance (cash surrender value only) ......
33. Charge-offs
.........................................
13. Other (specify)
.......................................
34.
..............................................
35.
..............................................
Real Estate
14. Residences ........................................................
Other Liabilities
15. Rental or investment property ..........................
36. Personal estimated taxes payable .........
16. Other (specify)
.......................................
37. Real estate estimated taxes payable......
Other Assets
38. Other estimated taxes payable ..............
*
17. Business interests
............................................
39. Insurance payable .................................
*
18. Accounts receivable
........................................
40. Accounts payable .................................
4
19. Vehicles
...........................................................
41. Other (specify)
...........................
20. Other (specify)
.......................................
42. Other (specify)
...........................
21. Total assets
43. Total liabilities
44. Total assets (line 21) ...........................
45 Minus: Total liabilities (line 43) ..........
46. Equals: Net worth .................................
List on page 3
440-5370 (10/19/COM)
Page 1
Oregon Department of Consumer and Business Services
Division of Financial Regulation
350 Winter St. NE, Room 410, Salem, Oregon 97301-3881
Mailing address: P.O. Box 14480, Salem, OR 97309-0405
503-378-4140  Fax: 503-947-7862
dfr.oregon.gov
Licensee name:
CRD/NMLS number:
Personal Balance Sheet
Cost
Method of valuation used (use same method for all assets):
Market Value
Asset
Value
Liabilities
Balance
Cash
Real Property
1. Checking account ...............................................
22. Primary residence mortgage .................
2. Savings account ..................................................
23. Home equity line of credit (HELOC) ..
3. Other (specify)
.........................................
24. Other residence mortgages ..................
25. Rental/investment property
Investments
26. Other (specify)
...........................
4. Stocks
................................................................
*
5. Bonds
.................................................................
Loans
6. Certificates of Deposit (CDs) ............................
27. Vehicle loans .......................................
7. Mutual funds .......................................................
28. Credit card debt ....................................
8. Other (specify)
.........................................
29. Personal loans ......................................
Retirement
30. Student loans .......................................
9. 401(k) or 403(b) ................................................
31. Other (specify)
...........................
10. Individual retirement accounts (IRAs) ............
Liens/Judgments/Compromises/Etc.
*
11. Keogh (vested interest) ....................................
32. Compromise with creditors
.................
*
12. Life insurance (cash surrender value only) ......
33. Charge-offs
.........................................
13. Other (specify)
.......................................
34.
..............................................
35.
..............................................
Real Estate
14. Residences ........................................................
Other Liabilities
15. Rental or investment property ..........................
36. Personal estimated taxes payable .........
16. Other (specify)
.......................................
37. Real estate estimated taxes payable......
Other Assets
38. Other estimated taxes payable ..............
*
17. Business interests
............................................
39. Insurance payable .................................
*
18. Accounts receivable
........................................
40. Accounts payable .................................
4
19. Vehicles
...........................................................
41. Other (specify)
...........................
20. Other (specify)
.......................................
42. Other (specify)
...........................
21. Total assets
43. Total liabilities
44. Total assets (line 21) ...........................
45 Minus: Total liabilities (line 43) ..........
46. Equals: Net worth .................................
List on page 3
440-5370 (10/19/COM)
Page 1
Licensee name:
CRD/NMLS number:
Personal Income Statement
You MUST complete this page if your net worth on line 46 of the previous page was negative or if you have outstanding
compromises, judgments, liens, or charge-offs. Use the average of the past 12 months to calculate the monthly amount.
Monthly Revenue
Amount
Monthly Expenses (Continued)
Amount
1
47. Commissions
...................................................
69. Childcare expense ................................
48. Salary ................................................................
70. Clothes ..................................................
49. Child/spousal support received .........................
71. Liens/judgments (list separately)
50. Business interest ...............................................
72.
..............................................
51. Real estate income ............................................
73.
..............................................
52. Investment income ............................................
74.
..............................................
53. Other (specify)
.......................................
75. Compromise with creditor ...................
54. Other (specify)
.......................................
76. Taxes ....................................................
55. Other (specify)
.......................................
77. Credit card payments ............................
56. Total revenue
78. Student loans ........................................
79. Other loans ...........................................
2
Monthly Expenses
80. Life insurance .......................................
57. Mortgage/rent ...................................................
81. Other insurance ....................................
58. Other real estate loans) .....................................
82. Entertainment .......................................
59. Property taxes ...................................................
83. Unreimbursed business expenses .........
60. Homeowner/renter insurance ............................
84. Medical/dental expenses ......................
61. Child/spousal support paid ...............................
85. Other (specify)
..........................
3
62. Utilities
............................................................
86. Other (specify)
..........................
63. Other household expenses ................................
87. Other (specify)
..........................
64. Food ..................................................................
88. Total expenses
4
65. Vehicle loans
...................................................
66. Vehicle insurance ............................................
89. Total revenue (line 56) ........................
67. Gas ...................................................................
90. Minus: Total expenses (line 88) ..........
68. Other vehicle expenses .....................................
91. Equals: Net income ..............................
Licensee name:
CRD/NMLS number:
1
If your income is listed as before tax, be sure to include the taxes on line 76.
2
For all items, include the monthly amount due, as well as any monthly payments toward past due amounts.
3
Include expenses related to water, electricity, gas, garbage, recycling, phone, Internet, etc.
4
Vehicle throughout this document includes cars, trucks, SUVs, all-terrain vehicles (ATVs), motorcycles, scooters, boats, recreational
vehicles, and campers.
440-5370 (10/19/COM)
Page 2
Use this page to:
o List information from the balance sheet. Reference the corresponding line number.
o If you have a negative net worth, explain the steps you are taking to reduce or resolve outstanding debts on the
balance sheet.
o Provide any explanation you want to help us better understand your financial situation.
Certification
This Personal Balance Sheet and, if completed, Personal Income Statement, including all footnotes and attachments to
this document, are a true, complete, and correct statement of my financial condition as of the date it was signed. I further
certify that the statements in this document are true and complete. I understand that any omitted statement,
misrepresentation, or fraud may be cause for denial of my application, disciplinary action, or may be punishable by law.
Signature:
Date:
440-5370 (10/19/COM)
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