Fill and Sign the Instructions You Are Required to Complete and File the 813b If Form

400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 1 of 7 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Name DOB V. Defendant Name DOB FINANCIAL AFFIDAVIT (400-813B) Property and Assets I am: ☐ Plaintiff ☐ Defendant ☐ Other: _____________________ Name Street Address Mailing Address (if different from Street Address) Town/City State Zip Town/City State Zip Phone Number (day) Phone Number (evening) Email Address INSTRUCTIONS: You are required to complete and file the 813 B if- 1. You are a party in a newly filed divorce, civil union dissolution, legal sep aration or annulment and you and the other party have minor children; OR 2. You are ordered by the Court to complete and file this form or the other party requests that you fill out the form as part of the discovery process. DEADLINE FOR FILING: This form must be filed with the court before or at your first case manager's conference. If no conference is scheduled it must be filed at least seven (7) days before your first scheduled court hearing. YOU MUST SEND A COPY OF YOUR COMPLETED FORM TO THE OTHER PARTY AT THE SAME TIME YOU FILE IT WITH THE COURT. When you have completed the form and filled in all the required information, you must sign the Affirmation sect ion below and have your signature notarized. AFFIRMATION I have read and filled in all the information requested. I hereby affirm of my own knowledge that the facts and financial info rmation I have stated are true and correct as of the date of this Affirmation and that I am not omitting any source or amount of income or other information re quested on this form. I understand that any false information may constitute perjury by me. I also understand that if I fail to provide the required information or give misinformation, the judge may order sanctions against me. _____________________________________________________________ Sworn to me on __________ __________________________________ My Commission Expires: ___________ Signature of Person Making A ffidavit Signature of Notary Public 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 2 of 7 SUMMARY OF ASSETS Check each box that applies to you or the other party REAL ESTATE : (primary residence, camps, land, timeshares, etc.) I have an interest in (own) real estate either individually or jointly with another. ☐ Yes ☐ No The other party has/may have an interest in (own) real estate either individually or jointly with another. ☐ Yes ☐ No PERSONAL PROPERTY : (furniture, antiques, jewelry, electronics, etc .) I own personal property ☐ Yes ☐ No The other party owns/may own personal property ☐ Yes ☐ No VEHICLES : (cars, trucks, ATV's, boats, motorcycles, campers, etc.) I own vehicles either individually or jointly. ☐ Yes ☐ No The other party owns/may own vehicles either individually or jointly ☐ Yes ☐ No BANK ACCOUNTS : I have bank accounts either individually or jointly. ☐ Yes ☐ No The other party has/may have bank accounts either individually or jointly. ☐ Yes ☐ No INVESTMENTS : (stocks, bonds, mutual funds, trusts, annuities) I own investments either individually or jointly. ☐ Yes ☐ No The other party owns/may own investments either individually or jointly. ☐ Yes ☐ No RETIREMENT ACCOUNTS (IRA, 401 K, pensions, deferred compensation, etc.) I own retirement accounts. ☐ Yes ☐ No The other party owns/may own retirement accounts. ☐ Yes ☐ No LIFE INSURANCE POLICIES : I have life insurance. ☐ Yes ☐ No The other party has/may have life insurance. ☐ Yes ☐ No BUSINESSES : I own or have an ownership interest in a business. ☐ Yes ☐ No The other party owns/may own an interest in a business. ☐ Yes ☐ No TRANSFER/SALE OF ASSETS Have you or the other party sold or transferred ownership of any asset in the last 12 months? ☐ Yes ☐ No Have you or the other party withdrawn funds from an account in the last 12 months for a purpose other than paying normal household expense payments? ☐ Yes ☐ No If you answered ''Yes'' to either of the above questions, please list asset sold or transferred OR account from which withdrawal was made, amounts received or withdrawn and any expenditure made from amounts received. _________________________________________________________________________________ _____________________ _________________________________________________________________________________ _____________________ _________________________________________________________________________________ _____________________ YOU MUST COMPLETE THE REMAINING PAGES OF THIS FORM IF YOU ANSWERED ''YES'' TO ANY OF THE QUESTIONS ABOVE. IF YOU ANSWERED ''NO'' TO ALL QUESTIONS ABOVE, YOU DO NOT HAVE TO COMPLETE THE REMAINING PAGES OF THIS FORM. 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 3 of 7 SECTION I - REAL ESTATE Description of Property Including Location Market Value Mortgages, Liens, Attachments Equity (value minus liens) Primary Residence: Second Home: Camp: Timeshare: Unimproved Land: Mobile Home: Residential Rental Real Estate Owned: Commercial Real Estate: Other Real Estate Interests: a. b. c. d. e. TOTAL VALUE OF REAL ESTATE INTERESTS IF ANY OF THE ABOVE PROPERTIES GENERATE RENTAL INCOME, YOU MUST EITHER: 1. ATTACH SCHEDULE E FROM YOUR LAST 2 TAX RETURNS or if you did not file taxes 2. FILL OUT RENTAL INCOME ATTACHMENT (See 400-00813A) 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 4 of 7 SECTION II - PERSONAL PROPERTY List all personal property owned by you and/or the other party. In estimating t h e market value, please use the amount you could reasonably receive if you sold the item today. Do not use the purchase price or replacement value. Description of Items Market Value Check if I tem is in Your Possession Loans/Debts on Property Person P aying on Loan/Debt Jewelry Antiques Artwork Guns Coins/Stamps Tools Collectibles Piano/Musical instruments China/Crystal/Silverware Appliances Electronics Furnishings Computers Other: a. b. c. 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 5 of 7 SECTION III - VEHICLES and BOATS “Market value” for motor vehicles is the retail value indicated in the NADA Blue Bo ok or other similar price guide. Title Holder Vehicle Description (Year, Make, Model) Market Value Outstanding Loan Amount Equity (Value minus Loan) Car #1 Car #2 Truck #1 Truck #2 Motorcycle #1 Motorcycle #2 Boat #1 Boat #2 Snowmobile #1 Snowmobile #2 ATV #1 ATV #2 Camper RV Plane Other Vehicles: a. b. SECTION IV - BUSINESS OWNERSHIP Owner Name of Business, Type of Business Activity and Legal Structure of Business (e.g. Sole proprietor, Partnership, Corporation, S- Corporation) % of Interest Owned Date of L ast Valuation Fair Market Value You Must Attach f o r m 4 0 0 - 0 0 8 1 3 A Self Employment Attachment or a Schedule C and/or Form K-1 from your last two (2) federal income tax returns for any business from which you earn or receive income, profits, distributions, in-kind income, etc. 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 6 of 7 SECTION V - INVESTMENTS Owner Type of Investment (Stocks, B onds, A nnuities, Mutual Funds, Trusts, etc.) Description (Name of Company, F und, Bank, Trust and Trustee etc.) Number of Shares Market Value SECTION VI - BANK ACCOUNTS and CASH Owner TYPE OF ACCOUNT Bank Current Balance Checking Account #1 Checking Account #2 Savings Account #1 Savings Account #2 Money Market Account #1 Money Market Account #2 Cash in your possession Tax Exempt College Funds or Other College Savings accounts Health Savings Accounts Other Accounts SECTION VII - ACCOUNTS/F UND S HELD FOR YOUR OR THE OTHER PARTY'S BENEFIT Trustee or Holder Name of Beneficiary Type of Account Current Value 400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 7 of 7 SECTION VIII - LIFE INSURANCE POLICIES Name Of Insured Beneficiary Company Face Value Loan Balance Cash Value SECTION IX - RETIREMENT ACCOUNTS Owner TYPE OF ACCOUNT Financial Institution Value IRA #1 IRA #2 401(k) #1 401(k) #2 403(b) TIAA/CREF Keogh TDSP TSA Profit Sharing Savings & Security Program Deferred Compensation Other Other SECTION X - PENSIONS Owner TYPE OF PENSION Pension Administrator Value Defined Benefit Defined Contribution Target Benefit Military Pension SEP