A financial responsibility form is used to indicate that an individual takes full financial responsibility for all expenses incurred. This form outlines the particular expenses that an individual is financially responsible for. It is an important document to have for accurate documentation and recording of information. It’s a simple document.
Sample financial responsibility form
Please fill in the following information accurately and honestly.
First name: _________________________ Middle name: ________________________
Last name: _________________________ Address: ____________________________
State: _____________________________ Location: ___________________________
Zip code: __________________________ Tel no: _____________________________
Mob no: ___________________________ Fax no: _____________________________
Email address: ______________________
Bank name: ________________________ Account type: ________________________
Account number: ____________________ Branch name: ________________________
Branch number: _____________________
Please fill in the blank spaces below as relates to you.
I ______________________ do on this day ________________ of month
_____________ Year ____________________ acknowledge full financial responsibility
For ______________________ for a duration of __________________________ from
_____________________ to __________________
Please sign here below:
Sig: _________________________________ Date: ______________