Fill and Sign the Financial Statements Only in Connection with Prenuptial Premarital Agreement Louisiana 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: Individual Information Name: Address: City: Occupation: Phone: Current Assets Date: State: Zip Current Liabilities Cash on Hand or in Banks Other Cash: Real Estate (other than residence Schedule A) Residence Notes Payable (Secured)(Schedule F) Notes Payable (Unsecured)(Schedule G) Real Estate Mortgages Payable (Schedule H) Auto Loans (Schedule I) 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 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 Financial Statement page - 1 - Cost Market Value Date Acquired Initials: _________ Totals SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value Date Acquired Par Value Market Value Date Acquired Par Value Market Value Date Acquired Par Value Market Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Totals SCHEDULE “D” NON MARKETABLE SECURITIES Description Totals SCHEDULE “E” STOCKS Company Financial Statement page - 2 - Shares Initials: _________ Totals 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) Date Balance Payment (m/yr) Totals Totals SCHEDULE “I” AUTO LOANS Description 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: Individual Information Name: Address: City: Occupation: Phone: Current Assets Date: State: Zip Current Liabilities Cash on Hand or in Banks Other Cash: Real Estate (other than residence Schedule A) Residence Notes Payable (Secured)(Schedule F) Notes Payable (Unsecured)(Schedule G) Real Estate Mortgages Payable (Schedule H) Auto Loans (Schedule I) 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 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 Financial Statement page - 1 - Cost Market Value Date Acquired Initials: _________ Totals SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value Date Acquired Par Value Market Value Date Acquired Par Value Market Value Date Acquired Par Value Market Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Totals SCHEDULE “D” NON MARKETABLE SECURITIES Description Totals SCHEDULE “E” STOCKS Company Financial Statement page - 2 - Shares Initials: _________ Totals 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) Date Balance Payment (m/yr) Totals Totals SCHEDULE “I” AUTO LOANS Description 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: _________