Prenuptial Agreement

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:

Other Cash:

Real Estate (other than residence Schedule A):

Residence:

Motor Vehicles (Schedule B):

US Government Securities (Schedule C):

Non-Marketable Securities (Schedule D):

Stocks (Schedule E):

Other Personal Property:

Life Insurance Cash Value:

Business IRA:

Notes Receivable:

Other Assets:

Personal IRA:

Antiques:

Partnership Assets:

Notes Payable (Secured) (Schedule F):

Notes Payable (Unsecured) (Schedule G):

Real Estate Mortgages Payable (Schedule H):

Auto Loans (Schedule I):

Unpaid Taxes and Interest:

Due to Brokers:

Open Accounts:

Credit Cards (List):

Visa:

Other:

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:

SCHEDULE “A” REAL ESTATE

Description of Real Estate Cost Market Value Date Acquired

SCHEDULE “B” MOTOR VEHICLES

Description of Motor Vehicles Cost Value

SCHEDULE “C” U.S. GOVERNMENT SECURITIES

Description of Stock or Bond Date Acquired Par Value Market Value

SCHEDULE “D” NON MARKETABLE SECURITIES

Description Date Acquired Par Value Market Value

SCHEDULE “E” STOCKS

Company Shares Date Acquired Par Value Market Value

SCHEDULE “F” NOTES PAYABLE SECURED

Description Date Balance Payment (m/yr)

SCHEDULE “G” NOTES PAYABLE UNSECURED

Description Date Balance Payment (m/yr)

SCHEDULE “H” REAL ESTATE MORTGAGES

Description Date Balance Payment (m/yr)

SCHEDULE “I” AUTO LOANS

Description Date Balance Payment (m/yr)

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 .

I acknowledge receipt of this financial statement and disclosure.

Initials:

Initials:

Initials:

Initials: