Fill and Sign the Asset Statement Form 497304480

STATE OF HAWAII FAMILY COURT       CIRCUIT ASSET AND DEBT STATEMENT Plaintiff Defendant Both Parties CASE NUMBER       FC-D NO.       _______________________________________ PLAINTIFF (Your Full Name) VS. _______________________________________ DEFENDANT (Your Spouse’s Full Name) This document is prepared by Plaintiff Attorney For Plaintiff Atty. For Defendant _______________________________________ Name _______________________________________ _______________________________________ Address _______________________________________ City, State, Zip _______________________________________ Phone 1. Cash (on hand or held by others for me) $ _______________________________________ 2. CREDIT UNION ACCOUNTS: Name Title (H, W, J) Credit Balance Debt Balance _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 3. BANK AND SAVINGS ACCOUNTS: (Include Trustee Accounts) Company and Branch Type of Account Title (H, W, J) Current Balance _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 4. SECURITIES: (Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.) Company Title (H, W, J) Date of Acquisition Cost Market Value Debt Owed Against _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ Page 2 5. VEHICLES: (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.) Year Make Title (H, W, J) Current Market Value Debt Owed Against _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 6. REAL PROPERTY: Date of Current Total Address Fee or Lease Title (H, W, J) Acquisition Cost Gross Value Debt Owed _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 7. LIFE INSURANCE: Title Debt Owed Company Person Insured Face Amount Beneficiary (H, W, J) Cash Value Against _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS: Total Employer or Company Title (H, W, J) Type of Plan Years in Plan Value _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 9. ALL OTHER MAJOR ASSETS: (Furniture, Household Effects, Art, Stamps, Coins, Tools, Equipment, Jewelry, Accounts Receivable, Investment Assets, Business Assets, Cemetery Plots or Niches, Tax Refunds Due, etc.) General Description Title (H, W, J) Estimated Gross Value Debt Owed Against _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ Page 3 10. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON/S: (Aside from Bank & Savings Accounts Noted in paragraph 3) Descriptions Trustee/s Beneficiaries Value Debt Owed Against _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ 11. ALL OUTSTANDING DEBTS: (Include those listed parts in 2, 4, 5, 6, 7, 9, and 10 above, in addition to all credit cards, charges, finance companies, and personal loans.) Debtor Mo./Yr. Total Minimum Monthly Creditor (H, W, J or Other) Security Debt Incurred Balance Owed Payment _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ Total Debt in Wife’s Name Alone: _______________________________________ ___________ Total Debt in Husband’s Name Alone: ________________________ _______________________ Total Debt in Joint Names: _______________________________________ _________________ CERTIFICATION I hereby declare under the penalty of perjury that I have supplied the information used in this Asset and Debt Statement and have reviewed this statement and I certify that the information is accurate, complete and correct. DATE       PLAINTIFF’S DEFENDANT’S SIGNATURE DATE       PLAINTIFF’S DEFENDANT’S SIGNATURE