ACKNOWLEDGEMENT OF RIGHTS AND OBLIGATIONS
RE: PREMARITAL AGREEMENT BETWEEN AND
.
I , hereby acknowledge my understanding of the following
rights and obligations of the parties to a Premarital Agreement under the laws of the State of
California:
1. ASSETS
California is a community property state. All property acquired by a married person during
their marriage while living in California is presumed to be community property. Upon
death or divorce, the value of all community assets is divided equally in terms of value
between both spouses.
Both marital partners are equal agents of the partnership, and able to bind the partnership if
acting within the scope of his or her authority and if acting for the joint benefit of the family.
The California community property system adds to joint ownership the right of equal
management and control.
All benefits which come from either spouse's employment during the marriage are
community property to the extent they are earned and/or accrued during the marriage. This
can include retirement benefits, pensions, savings plans, stock purchase plans, 401k plans,
sick and vacation pay, and stock options. If the benefits are not fully vested at the time of a
separation, an allocation is made between the community and separate interests.
Separate property is property: a) owned before marriage, b) acquired during marriage by gift
or inheritance, or c) acquired after separation. Earnings, income or appreciation from separate
property sources remains separate property. If there is a dispute about whether an asset is
separate property, you must have proof that you acquired the separate property in one of these
ways, and have documentation to trace the separate property back to the original source.
If you use separate property to acquire property in joint names during the marriage, you are
only entitled to reimbursement for the amount of the separate property contributed (no interest
or appreciation) and again, you must be able to trace the contribution back to the separate
property source.
If you own a business prior to marriage, the community may acquire an interest in the
business if the business increases in value during the marriage, depending upon the reason for
the increase in value.
If you own a home in your own name and community funds are used for mortgage payments
or to pay down the principal on a loan, the community will acquire an interest in the
appreciation in the value of the property, but only in the ratio that the amount paid on
principal bears to the total purchase price. The community will also be reimbursed for the
amount paid down on principal.
- 1 -
The way you hold title to real property will affect disposition of property upon death of a
spouse. For example, property held as joint tenants will automatically become the property of
the surviving spouse. Property held as community property or tenants in common will be
distributed according to the will or trust of the spouse, or according to the laws governing
intestate succession in the absence of a will or a trust.
2. DEBTS
Debts incurred during the marriage are presumed to be community property. The only debts
which would normally not be community property are debts which are completely unrelated
to the community (such as debts related to one person's separate property, support
obligations, gifts or expenses related to a romantic relationship other than the marriage, or
criminal acts which did not have a financial benefit to the community). These means that a
spouse could incur a debt for a purpose the other spouse does not approve and it would still
be a community debt.
Debts incurred before marriage remain the responsibility of the person who originally
incurred them. If community funds are used to pay these debts, sometimes there is a right of
reimbursement for the community and sometimes not (special rules apply depending upon the
type of debt and other assets/income which was available to pay it.)
3. DIVISION OF ASSETS AND DEBTS UPON DIVORCE
In dissolution of a marriage, the court is empowered to allocate assets of comparable value to
the former husband and wife to make the overall division of the gross marital estate
substantially equal. It need not divide each asset. For example, when dividing a business
might impair its value, the court will generally preserve the ongoing business interests if the
court can still make an overall equal division of the marital estate.
If you own a home together and one spouse continues to reside in the home after separation,
that spouse could owe "rent" to the community, subject to an offset for payment of the costs
of the home.
If one spouse pays on community debts after separation, he or she will generally be
reimbursed for those payments (the biggest exception would be if the debt payments are in
lieu of support.).
4. SUPPORT
Each spouse owes a duty of support to the other. Support can be ordered after separation. The
amount and duration of support is set by the court and can depend on many factors.
Spouses are permitted to waive the right to support upon divorce in a premarital agreement.
Certain conditions must be met, including that each spouse be represented by an attorney for
the premarital agreement. In addition, a court could later order spousal support even if it was
waived if it would be unconscionable not to order it.
5. CHILDREN
- 2 -
Each parent is entitled to custody of the children. Upon a separation, the court determines
custody according to the best interest of the child. Child support is payable according to a
standardized formula.
Premarital agreements cannot waive or change the authority of the court to make orders of the
court regarding children.
6. PREMARITAL AGREEMENTS
Under California law, the property rights of husband and wife prescribed by statute may be
altered by a premarital agreement.
A premarital agreement may be recorded in the office of the recorder of each county in which
real property affected by the agreement is situated if the premarital agreement is executed and
acknowledged or proved in the manner that a grant of real property is required to be executed
and acknowledged or proved. Recording or nonrecording of a premarital agreement or other
marital property agreement has the same effect as recording or nonrecording of a grant of real
property.
Information on the enforceability of premarital agreements is contained in the “Premarital
Agreement Disclosure” that was received and signed concurrently with this
“Acknowledgement of Rights and Obligations.”
7. BY EXECUTING THE PREMARITAL AGREEMENT YOU WILL BE WAIVING
ALL OF THE FOLLOWING RIGHTS:
(a) Division of community and quasi-community property;
(b) Support to either spouse in any amount and for any period of time that the court
deems just and reasonable, based on the standard of living achieved during the marriage; and
(c) The award of marital assets by the court on such conditions as it feels proper to provide for a
substantially equal distribution of property.
This statement of Rights and Obligations has been provided by
.
I, , hereby acknowledge receipt of this Declaration of
Rights and Obligations on this the day of , 20
Signature
Type or Print Name
- 3 -
ADVISEMENT AND WAIVER OF RIGHT TO
INDEPENDENT COUNSEL
RE: PREMARITAL AGREEMENT BETWEEN
AND .
NAME OF DECLARANT: .
RIGHT TO BE REPRESENTED BY AN ATTORNEY. I have been advised to seek
independent counsel regarding a proposed premarital agreement between myself and .
I am either currently in a position to afford independent counsel of my own choice or, if I can
not afford independent legal counsel, I understand that
has agreed to compensate me for the cost of independent counsel to act solely under my
direction and control.
WAIVER. I understand that I am giving up the rights stated above and hereby waive the right to
independent counsel.
Signature of Declarant
Type or Print Name
State of California
County of
On before me, (here
insert name and title of the officer), personally appeared
, who proved to me on the basis of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s)
acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
PREMARITAL AGREEMENT DISCLOSURE
AS STATED BELOW, IT IS VERY IMPORTANT THAT YOU BE REPRESENTED BY
INDEPENDENT COUNSEL, OR WAIVE SUCH RIGHT. SEVEN (7) DAYS MUST PASS
BEFORE EXECUTION OF THE AGREEMENT AS PROVIDED BELOW.
NOTICE:
The parties understand fully the laws of California dealing with the validity of premarital
agreements, including, but not limited to the following:
(a) A premarital agreement is not enforceable if the party against whom enforcement is
sought proves either of the following:
(1) That party did not execute the agreement voluntarily.
(2) The agreement was unconscionable when it was executed and, before execution
of the agreement, all of the following applied to that party:
(A) That party was not provided a fair, reasonable, and full disclosure of
the property or financial obligations of the other party.
(B) That party did not voluntarily and expressly waive, in writing, any
right to disclosure of the property or financial obligations of the other
party beyond the disclosure provided.
(C) That party did not have, or reasonably could not have had, an
adequate knowledge of the property or financial obligations of the
other party.
(b) An issue of unconscionability of a premarital agreement shall be decided by the court
as a matter of law.
(c) For the purposes of subdivision (a), it shall be deemed that a premarital agreement
was not executed voluntarily unless the court finds in writing or on the record all of
the following:
(1) The party against whom enforcement is sought was represented by
independent legal counsel at the time of signing the agreement or, after being
advised to seek independent legal counsel, expressly waived, in a separate
writing, representation by independent legal counsel.
(2) The party against whom enforcement is sought had not less than seven
calendar days between the time that party was first presented with the
agreement and advised to seek independent legal counsel and the time the
agreement was signed.
- 1 -
(3) The party against whom enforcement is sought, if unrepresented by legal
counsel, was fully informed of the terms and basic effect of the agreement as
well as the rights and obligations he or she was giving up by signing the
agreement, and was proficient in the language in which the explanation of the
party's rights was conducted and in which the agreement was written. The
explanation of the rights and obligations relinquished shall be memorialized in
writing and delivered to the party prior to signing the agreement. The
unrepresented party shall, on or before the signing of the premarital
agreement, execute a document declaring that he or she received the
information required by this paragraph and indicating who provided that
information.
(4) The agreement and the writings executed pursuant to paragraphs (1) and (3)
were not executed under duress, fraud, or undue influence, and the parties did
not lack capacity to enter into the agreement.
(5) Any other factors the court deems relevant.
WE HAVE FULLY READ AND UNDERSTAND THE ABOVE LAWS AND WERE
PROVIDED THIS DISCLOSURE, A COPY OF THE PROPOSED PREMARITAL
AGREEMENT AND WERE ADVISED TO SEEK INDEPENDENT COUNSEL AT LEAST
SEVEN (7) DAYS BEFORE EXECUTION OF THE ACTUAL AGREEMENT .
HUSBAND TO BE
WIFE TO BE
DATE SIGNED MUST BE AT LEAST SEVEN DAYS BEFORE SIGNING THE
AGREEMENT.
- 2 -
PREMARITAL AGREEMENT
THIS AGREEMENT, made this ____ day of ________________ , 20 ____ , between
___________________________ (Name), of ______________________________ (Address),
_____________ (State) ("first party or Wife"), and _____________________ (Name), of
____________________________ (Address), _____________ (State) ("second party or
Husband"),
W I T N E S S E T H
WHEREAS, Husband (check all that apply):
has previously been married;
has a child or children;
has not been married; and
Wife (check all that apply):
has previously been married;
has a child or children;
has not been married.
The parties desire to enter into this agreement prior to their contemplated marriage.
WHEREAS, the parties hereto have accumulated separate estates; and
WHEREAS, the parties are about to contract marriage and execute this agreement in
contemplation of marriage to be effective upon their marriage in accordance with the laws of the
State of California, including any Uniform Premarital Agreement Act, or other applicable laws,
adopted by the State of California; and
WHEREAS, the parties desire to enter into an agreement regarding certain properties,
responsibilities, duties and obligations including but not limited to any interest, present or future,
legal or equitable, vested or contingent, in real or personal property, including income and earnings;
and
WHEREAS, the parties have furnished each other with a financial statement which each
party acknowledges is a full and complete disclosure of substantially all of the real and personal
property now owned by him or her and agree that the values are an estimate by him or her of the
approximate present value of the property. All property listed is now and shall continue to be
separate properties of the respective parties. Originals or copies of said financial statements are
attached hereto as Exhibits "A" and "B"; and
- 1 -
WHEREAS, the parties desire to express in writing their agreement that, except as
hereinafter specifically provided, their marriage shall not in any way change their rights, or the
rights of their heirs (exclusive of the parties) or of their devisees or legatees, in the real and personal
property owned or hereafter acquired by each of the parties and that said rights shall be governed by
the terms of this agreement; and
NOW, THEREFORE, in consideration of the parties and of their mutual promises and
agreements, they agree one with the other as follows:
(1) Each of the parties shall have full control of his or her own separate property, real,
personal and mixed, wherever the property is located. Each of the parties shall have and hereby is
given the right to lease, sell, convey, mortgage or otherwise dispose of their separate property and
receive all monies, rents, issues, income and profits thereof without any restrictions whatever and
without interference from the other party. Each of the parties shall pay his or her own debts
whenever contracted and in no case shall either party be held liable for the debts of the other parties
in any way.
(2) Except as otherwise expressly provided, each of the parties hereby waives,
relinquishes, conveys, quitclaims, bars, discharges, surrenders and releases, and hereby agrees to
waive, relinquish, convey, quitclaim, bar, discharge, surrender and release, to the other all of the
following:
(a) Any and all of his or her right, title and interest of every kind and description, which
he or she may have, acquire, enjoy or be seized by reason of, or on or after, their marriage, as the
wife, husband, widow or widower of the other party, in the separate property of the other party,
whether real, personal and mixed and wherever located; and
(b) Any and all rights to any property of the other party titled in that other parties sole
name, whether before or after the marriage; and
(c) Any and all property acquired by the other party by inheritance or other means; and
(d) Any and all rights, if any, to all or a portion of the property of the other party
whether by way of dower, courtesy, homestead, widow's allowance, statutory share or provision,
descent, community property inheritance, succession or otherwise;
(e) His or her right, if any, granted to or vested in him or her, by statute or otherwise, to
renounce, or to elect to take against, the provisions of the other party's will or any codicil thereto;
and
(f) His or her right, if any, granted to or vested in him or her by statute or otherwise to
act as executor or administrator of the other party's estate.
Except as otherwise expressly provided, it is the intent of the parties that this paragraph
shall be construed so that each party may deal with his or her property and any trust in which he or
she may have an interest as if their marriage had not taken place, and on the death of either party his
or her estate and any trust in which he or she may have an interest will be administered, descend
and be distributed in exactly the same way and to the same heirs, next of kin, devisees or legatees as
- 2 -
if the other party had predeceased the party so dying. Nothing contained in this paragraph or in this
agreement, however, is intended to preclude either party from voluntarily making provision for, or
granting powers or rights to, the other party in and by the formers last will, a codicil thereto or
otherwise.
(3) (check One)
The parties have each executed a Last Will and Testament, copies of which
are attached hereto as Exhibits and . The parties agree that these Wills
are in conformity with the provisions of this agreement and as consideration for this
agreement, each party does hereby waive any and all objection to the terms of the
said Last Will and Testament of the other and each party agrees not to contest or
renounce the terms of thereof. Likewise, each party agrees not to contest or
renounce any future Wills or Codicils, which are in conformity with the terms of
this agreement. Initials if Selected: _______ ______ __
OR
The parties shall not change their existing Will, if any, or make a new Will
at this time, but any new Will executed shall be in conformance with the provisions
of this agreement. Initials if Selected: _______ _________
(4) The fact that either party (without being obligated to do so) may give, devise or
bequeath to the other party property or an interest therein, or otherwise confer rights or powers on
the other party, in trust or by gift or will, shall not be construed as a waiver of any provision hereof
or as evidence that there is or was an agreement or understanding between the parties other than as
specifically expressed herein.
(5) Each party agrees, on behalf of himself or herself and of his or her heirs, executors,
administrators and assigns, that he, she or they, at the request of the other party or the latter's heirs,
executors, administrators and assigns (but at the cost of the other party or his or her heirs, executors,
administrators, and assigns), will make, do, execute, acknowledge and deliver any and all such
further or other acts, deeds and instruments as shall be appropriate, necessary or desirable to carry
in effect the intent, purpose and provisions of this agreement without question or delay, except that
neither party shall be obliged to sign any mortgage, note, bond or other instrument which may
subject him or her, or his or her estate and property, to personal liability.
(6) In selling, assigning, granting, releasing, conveying or otherwise dealing with the
property of either party, the party whose property is being so dealt with shall be and hereby is
constituted the other party's attorney-in-fact and as such shall have full power in the name of such
other party or in the joint names of both parties to join in the contemplated transaction and execute
documents to effect it on behalf of such other party, independently and without the consent or
privity of such other party, to the same extent and as fully as if their marriage had not taken place.
(7) During the course of the marriage, all property acquired by each party in their own
name shall be deemed to be part of their separate estate and by the terms hereof, each party hereby
waives and relinquishes all claim to the separate estate of the other. Likewise, all property acquired
during the marriage in the joint name of both parties shall be deemed to be part of their joint estates
- 3 -
and thereby evidence their intent to grant the powers and rights to the parties as to said jointly
owned property as is provided to spouses by operation of law.
(8) The parties agree that each party shall provide for the payment of their individual
health care, convalescence and funeral expenses out of their separate estate so as not to be a
financial burden on each other.
(9) Despite any other provisions of this instrument, this agreement shall not affect in
any way the parties' rights, titles, powers, duties, discretions, immunities and interest in any
property owned in joint tenancy or entirety with rights of survivorship, which they may hereafter
acquire.
(10) To the extent permitted by law, this agreement shall govern the rights and
obligations of the parties in the event of death of either or both parties, separation or divorce.
In the event of divorce, the parties agree this agreement shall be binding on both parties and shall be
incorporated into any divorce decree.
(11) Not applicable or The parties further agree that in the event of divorce, the
following additional provisions shall apply notwithstanding the other provisions of this agreement:
(a) The Wife shall be entitled to receive property of Husband described as
follows: [none or list property]
(b) The Husband shall be entitled to receive property of Wife described as
follows: [none or list property]
(c) The following property shall be sold and the proceeds, less expenses divided
equally between the parties: [none or list property]
(d) The Husband shall pay a lump sum settlement to Wife described as follows:
[none or list property]
(e) The Wife shall pay a lump sum settlement to Husband described as follows:
[none or list property]
(f) The marital domicile shall be [occupied by Wife until her death or occupied
by Husband until his death or sold and the proceeds divided equally between Husband and Wife.
(Choose One)
- 4 -
(g) Both parties waive the right to alimony and property settlement, except as
otherwise provided herein.
(h) Both parties waive all community property rights.
(12) This agreement shall be controlled, construed and given effect by and under the
laws of the State of California. It is the intent of the parties that the Agreement be enforced to the
fullest extent permissible under applicable laws and public policies. The invalidity, illegality, or
unenforceability of any particular provision of this Agreement shall not affect the other provisions,
and this Agreement shall be construed in all respects as if such invalid, illegal, or unenforceable
provision had been omitted.
(13) This Agreement constitutes the entire agreement between the parties pertaining to its
subject matter and it supersedes all prior contemporaneous agreements, representations and
understandings of the parties. No supplement, modification or amendment of this Agreement shall
be binding unless executed in writing by all parties.
(14) No waiver of any provision of this Agreement shall be deemed, or shall constitute, a
waiver of any other provision, whether or not similar, nor shall any waiver constitute a continuing
waiver. No waiver shall be binding unless executed in writing by the party making the waiver.
(15) This Agreement may be executed in any number of copies, each of which shall be
deemed an original and no other copy need be produced. All pronouns and any variations thereof
shall be deemed to refer to the masculine, feminine, neuter, singular or plural as the identity of the
person or persons may require.
(16) This Agreement shall be binding upon the parties hereto and upon their respective
executors, administrators, legal representatives, successors, and assigns.
(17) This agreement may only be amended or revoked by written amendment signed by
both parties.
(18) Each party further agrees and affirms as follows:
(a) That the party did execute the agreement voluntarily; and
(b) That this agreement is not unconscionable when it was executed; and
(c) Both parties were provided prior to execution of this agreement a fair and
reasonable disclosure of the property and financial obligations of the other party;
(d) That he and she did have, or reasonably could have had, an adequate
knowledge of the property and financial obligations of the other party.
- 5 -
The parties hereby execute this agreement in several counterparts, any executed copy of
which shall be considered for all purposes as an original, on the day and year above written.
HUSBAND (as used in this Agreement)
WIFE (as used in this Agreement)
APPROVED
Attorney for Husband APPROVED
Attorney for Wife
Note: This Agreement must be executed before a notary public.
State of California
County of
On before me, (here
insert name and title of the officer), personally appeared
, who proved to me on the basis of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s)
acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
State of California
County of
On before me, (here
insert name and title of the officer), personally appeared
- 6 -
, who proved to me on the basis of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s)
acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the
State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature (Seal)
- 7 -
Financial Statement Disclosure Information
This financial statement disclosure is for use in connection with a premarital agreement
and should be completed accurately and completely. This statement should contain a
full disclosure of all your assets and liabilities. You should initial each page and sign the
last page. Your prospective spouse should also sign the last page acknowledging
receipt.
Both persons must complete a separate financial statement and provide it to the other
party. Two forms are enclosed, one for each party.
This form can be completed in Word or printed and completed by hand.
If you require additional space, please attach additional pages for the sections you need
to expand.
PERSONAL FINANCIAL DISCLOSURE STATEMENT
******************************************************
To: Date:
Individual Information
Name:
Address:
City: State: Zip
Occupation:
Phone:
Current Assets
Current
Liabilities
Cash on Hand or in Banks Notes Payable (Secured)(Schedule F)
Other Cash: Notes Payable (Unsecured)(Schedule G)
Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H)
Residence Auto Loans (Schedule I)
Motor Vehicles (Schedule B) Unpaid Taxes and Interest
US Government Securities (Schedule C) Due to Brokers
Non-Marketable Securities (Schedule D) Open Accounts
Stocks (Schedule E) Credit Cards (List):
Other Personal Property Visa
Life Insurance Cash Value
Business IRA
Notes Receivable
Other Assets: Other:
Personal IRA
Antiques
Partnership Assets Residential Mortgage
Total Liabilities
TOTAL OF ALL ASSETS
LESS TOTAL OF ALL LIABILITIES
NET WORTH
Total Assets
Individual Income Information (Annual)
Salary
Bonus
Commissions
Dividends
Rental Income
Other Income (List):
Total Income
Contingent Liabilities
Guarantor, Co-maker
Lease or Contracts
Legal Claims
Other:
Financial Statement page - 1 - Initials: _________
SCHEDULE “A” REAL ESTATE
Description of Real Estate Cost Market Value Date Acquired
Totals
SCHEDULE “B” MOTOR VEHICLES
Description of Motor Vehicles Cost Value
Totals
SCHEDULE “C” U.S. GOVERNMENT SECURITIES
Description of Stock or Bond Date Acquired Par Value Market Value
Totals
SCHEDULE “D” NON MARKETABLE SECURITIES
Description Date Acquired Par Value Market Value
Totals
Financial Statement page - 2 - Initials: _________
SCHEDULE “E” STOCKS
Company Shares Date Acquired Par Value Market Value
Totals
SCHEDULE “F” NOTES PAYABLE SECURED
Description Date Balance Payment (m/yr)
Totals
SCHEDULE “G” NOTES PAYABLE UNSECURED
Description Date Balance Payment (m/yr)
SCHEDULE “H” REAL ESTATE MORTGAGES
Description Date Balance Payment (m/yr)
Totals
SCHEDULE “I” AUTO LOANS
Description Date Balance Payment (m/yr)
Totals
Financial Statement page - 3 - Initials: _________
CERTIFICATION TO FINANCIAL STATEMENT
I certify this Statement to be true and correct as of the date indicated;
that this financial statement is a full and fair disclosure of my assets;
and that I provided a true and correct copy of this financial statement to
___________________________________ on ___________________.
_________________________________
Signature
Date: ___________________________
I ___________________________________ acknowledge receipt of this financial
statement and disclosure.
________________________________________
Signature
Date: ___________________________________
Financial Statement page - 4 - Initials: _________
PERSONAL FINANCIAL DISCLOSURE STATEMENT
******************************************************
To: Date:
Individual Information
Name:
Address:
City: State: Zip
Occupation:
Phone:
Current Assets
Current
Liabilities
Cash on Hand or in Banks Notes Payable (Secured)(Schedule F)
Other Cash: Notes Payable (Unsecured)(Schedule G)
Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H)
Residence Auto Loans (Schedule I)
Motor Vehicles (Schedule B) Unpaid Taxes and Interest
US Government Securities (Schedule C) Due to Brokers
Non-Marketable Securities (Schedule D) Open Accounts
Stocks (Schedule E) Credit Cards (List):
Other Personal Property Visa
Life Insurance Cash Value
Business IRA
Notes Receivable
Other Assets: Other:
Personal IRA
Antiques
Partnership Assets Residential Mortgage
Total Liabilities
TOTAL OF ALL ASSETS
LESS TOTAL OF ALL LIABILITIES
NET WORTH
Total Assets
Individual Income Information (Annual)
Salary
Bonus
Commissions
Dividends
Rental Income
Other Income (List):
Total Income
Contingent Liabilities
Guarantor, Co-maker
Lease or Contracts
Legal Claims
Other:
Financial Statement page - 1 - Initials: _________
SCHEDULE “A” REAL ESTATE
Description of Real Estate Cost Market Value Date Acquired
Totals
SCHEDULE “B” MOTOR VEHICLES
Description of Motor Vehicles Cost Value
Totals
SCHEDULE “C” U.S. GOVERNMENT SECURITIES
Description of Stock or Bond Date Acquired Par Value Market Value
Totals
SCHEDULE “D” NON MARKETABLE SECURITIES
Description Date Acquired Par Value Market Value
Totals
Financial Statement page - 2 - Initials: _________
SCHEDULE “E” STOCKS
Company Shares Date Acquired Par Value Market Value
Totals
SCHEDULE “F” NOTES PAYABLE SECURED
Description Date Balance Payment (m/yr)
Totals
SCHEDULE “G” NOTES PAYABLE UNSECURED
Description Date Balance Payment (m/yr)
SCHEDULE “H” REAL ESTATE MORTGAGES
Description Date Balance Payment (m/yr)
Totals
SCHEDULE “I” AUTO LOANS
Description Date Balance Payment (m/yr)
Totals
Financial Statement page - 3 - Initials: _________
CERTIFICATION TO FINANCIAL STATEMENT
I certify this Statement to be true and correct as of the date indicated;
that this financial statement is a full and fair disclosure of my assets;
and that I provided a true and correct copy of this financial statement to
___________________________________ on ___________________.
_________________________________
Signature
Date: ___________________________
I ___________________________________ acknowledge receipt of this financial
statement and disclosure.
________________________________________
Signature
Date: ___________________________________
Financial Statement page - 4 - Initials: _________
