Legal Financial Statement

LEGAL FINANCIAL STATEMENT

This Legal Financial Statement is made on by Declarant Name: (Declarant) and delivered to Recipient Name: (Recipient) for the purposes set forth below.

RECITALS

WHEREAS, Declarant has been requested to disclose assets, liabilities, income and expenses to permit Recipient to evaluate Declarant's financial condition in connection with legal proceedings or settlement negotiations;

WHEREAS, Declarant has agreed to provide a complete and accurate statement of financial condition, and to authorize verification of the information set forth in this Statement; and

WHEREAS, Recipient requires the information contained in this Statement for the limited purpose described herein and for no other use without written consent of Declarant.

NOW THEREFORE, in consideration of the foregoing and the mutual covenants contained herein, Declarant and Recipient agree as follows:

1. IDENTIFICATION AND PURPOSE

Declarant Identification: Social/ID (last four or other identifier): ; Date of Birth: .

Purpose of Disclosure:

2. STATEMENT OF FINANCIAL CONDITION

Declarant represents that the following statement of assets, liabilities, income and expenses is true, complete and submitted in good faith. All amounts are current as of the date of this Statement unless otherwise stated.

3. INCOME

Employment status: . Employer or primary source of income: .

Gross monthly income (salary/wages): $ . Other monthly income (describe): $ .

4. ASSETS

Cash, Checking and Savings

Investments (brokerage, stocks, bonds)

Real Property

Vehicles

Retirement and Pension Accounts

Business Interests and Other Assets

5. LIABILITIES

Mortgages, Loans and Notes Payable

Credit Cards

6. MONTHLY EXPENSES

Housing (mortgage/rent): $ Utilities: $ Food: $

Transportation (payments, fuel, insurance): $ Medical and health care: $ Childcare/education: $

Insurance (life, disability, other): $ Other monthly obligations: $

7. SUPPORTING DOCUMENTS

The following supporting documents are attached or will be provided upon request (check applicable):
Pay stubs (most recent three)
Bank statements (most recent three months)
Federal and state tax returns (most recent two years)
Property deeds or mortgage statements
Vehicle titles/loan statements

Other supporting documentation (describe):

8. REPRESENTATIONS, AUTHORIZATION AND CERTIFICATION

Declarant represents and warrants that all information contained in this Statement and in any attachments is true, correct and complete to the best of Declarant's knowledge. Declarant acknowledges that material misstatements or omissions may constitute fraud and may subject Declarant to civil and criminal liability under applicable law.

Declarant authorizes Recipient and Recipient's agents to verify any information provided herein with any third party, including employers, financial institutions, taxing authorities, credit bureaus and other entities. Declarant agrees to provide additional documentation reasonably requested to support the information contained in this Statement.

Certification: I declare under penalty of perjury under the laws of the State of that the foregoing is true and correct and that I understand the legal consequences of willfully submitting false information.

Date of declaration:

9. MISCELLANEOUS PROVISIONS

Governing Law: This Statement and all disputes arising out of or relating to it shall be governed by the laws of the State of without regard to conflict of law principles.

Notices: All notices required or permitted under this Statement shall be in writing and delivered by personal delivery, recognized overnight courier, or first-class mail to the addresses set forth below. Declarant notice address:

Recipient notice address:

Amendments and Waiver: No amendment, modification or waiver of any provision of this Statement shall be effective unless in writing and signed by both Declarant and Recipient. A failure or delay in enforcing any provision shall not constitute a waiver of that provision.

Entire Agreement: This Statement, together with any attachments and exhibits hereto, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral.

Severability: If any provision of this Statement is held invalid or unenforceable by a court of competent jurisdiction, the remaining provisions shall continue in full force and effect to the greatest extent permitted by law.

Counterparts: This Statement may be executed in counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. Facsimile or electronic signatures shall be binding.

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