Fill and Sign the Financial Statements Only in Connection with Prenuptial Premarital Agreement Connecticut Form

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:             SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired                         Financial Statement page - 1 - Initials: _________                                                                                                                                                                                                                                                                                                                   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       SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value Financial Statement page - 2 - Initials: _________                                                                                                                                                                                     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             CERTIFICATION TO FINANCIAL STATEMENT Financial Statement page - 3 - Initials: _________ 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:             SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired                         Financial Statement page - 1 - Initials: _________                                                                                                                                                                                                                                                                                                                   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       SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value Financial Statement page - 2 - Initials: _________                                                                                                                                                                                     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             CERTIFICATION TO FINANCIAL STATEMENT Financial Statement page - 3 - Initials: _________ 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: _________