Fill and Sign the I Swear under Oath that I Have an Interest in the Following Property Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, SWORN STATEMENT OF ASSETS AND LIABILITIES AND , Respondent, STATE OF MINNESOTA ) ) SS. COUNTY OF ) I. I, ______________, swear under oath that I have an interest in the following property: Item Estimate of Value How Value Determined ____________ $_________ ____________ ____________ $_________ ____________ ____________ $_________ ____________ ____________ $_________ ____________ - 2 - II. I further swear under oath that the foregoing is a complete and accurate list of any interests I have in property and that I have not made any significant changes to any of my property int erests during the last 18 months except as follows: ________________________________________________________ III. I further swear under oath that I have the following liabilities: Creditor Balance Owed Monthly Payment ____________ $_________ $_________ ____________ $_________ $_________ ____________ $_________ $_________ ____________ $_________ $_________ ____________ $_________ $_________ ____________ $_________ $_________ ____________ $_________ $_________ III. I further swear under oath that there have been no significant changes to my liabil ities during the last 18 months except as follows: ________________________________________________________ - 3 - IV. I further swear under oath that my current gross income from all sources is $______________ per ______________ and that my gross annual income from all sources was $______________ for the preceding tax year. I receive no cash, which is not characterized as income for tax purposes except ______________. V. I understand that my failure to honestly, accurately, and completely disclose inc ome, assets or liabilities may be a fraudulent misrepresentation that would be cause for a redistribution of assets (and/or a predetermination of my (child support) (and) (maintenance) obligations after the dissolution). FURTHER YOUR AFFIANT SAITH NOT. Dated: _________________________ ____________________________ Name_____ Petitioner/Respondent Dated: Subscribed and sworn to before me this _____ day of _________________ , 20____ . _______________________________ NOTARY PUBLIC