Asset Evaluation Form


CONFIDENTIAL

Evaluation of Customer’s Ability To Pay

1. Employer Name, Address and Phone Number
________________________________________________________________________ ________________________________________________________________________

2. What is your monthly income? ___________________________________________

3. Please identify all other forms of income (Unemployment, Disability, and Public Assistance)
and the amounts of each
________________________________________________________________________
________________________________________________________________________

4. Please list all checking and savings accounts and balances:
________________________________________________________________________ ________________________________________________________________________

5. Please list all credit cards, balances due and the amount of the monthly payment on each: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

6. Do you own your home or do you rent? _____________________________________

7. What is your monthly mortgage or rent payment? ____________________________

8. List other assets (i.e., Stocks and Bonds) :
________________________________________________________________________
________________________________________________________________________

9. List other debts (bank loans, credit lines, utility bills, etc.) and the amount of the monthly payment on each: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

10. Identify all other monthly expenditures by amount:

— Food expenses $______________
— Medical expenses $______________
— Telephone bills $______________
— Utility bills $______________
— Mandatory loan/credit card payments $______________
— Other $______________

Download one of the following files to use in your Word Processor:

MS Word Document MS Word Document Rich Text Document Rich Text Document

About Us | Site Map | Privacy Policy | Website Disclaimer |Contact Us | Accessibility

© NYS Department of Public Service

This page last modified 11/17/14 01:00:02 PM