Statement of The Net Worth |
*This is required by INS and Russia to assess your financial ability to support your new family member(s), and it will be included in your dossier. |
Adoptive Mother’s Full Legal Name:
Adoptive Father’s Full Legal Name:
| Address: | Home Phone: | E-mail: |
| Mother’s Work: | Father’s Work: |
ASSETS |
LIABILITIES |
||||
| Cash on hand | __________ | Mortgage(s) | __________ | ||
| Investments | __________ | Notes | __________ | ||
| Savings | __________ | Credit Cards | __________ | ||
| Cash Surrender Value or Life Ins. | __________ | Taxes & Interest | __________ | ||
| Stocks & Bonds | __________ | Loans | __________ | ||
| Real Estate | __________ | TOTAL | __________ | ||
| Personal Prop. | __________ | ||||
| TOTAL | __________ | ||||
| NET WORTH | ||
| Total Assets _________________ | ||
| Total Liabilities _______________ | ||
| Net Worth __________________ | ||
| Adoptive Mother___________________________________________________________________ | |||
| Signature | Date | ||
| Adoptive Father____________________________________________________________________ | |||
| Signature | Date | ||
| On this ___day of _________, 19___, before me personally appeared _______________, |
| To me known to be the person who executed the forgoing document and acknowledged they executed the same as their free will, act and deed. |
| Witness my hand and seal, |
| ____________________________________________ |
| Notary Public |