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Fill and Sign the Non Marital Assets Form

Fill and Sign the Non Marital Assets Form

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VERIFIED STATEMENT IDENTIFYING MARITAL AND NON-MARITAL ASSETS Date of Commencement of action: __________ __________ Client Information: Petitioner or Respondent Name : __________ __________ __________ __________ __________ Address: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Social Security No: __________ Date of Birth: __________ Telephone No: (W) __________ (H) __________ Present Employer: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Position: __________ __________ __________ __________ __________ SPOUSE: Petitioner or Respondent Name: __________ __________ __________ __________ __________ Address: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Social Security No: __________ Date of Birth: __________ Telephone No: (W) __________ (H) __________ Present Employer: __________ __________ __________ __________ Address: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Position: __________ __________ __________ __________ __________ - 1 - MARITAL INFORMATION Date of Marriage: __________ City/State: __________ Children - Name (s) Birthday Age Residing With __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ __________ __________ __ __________ LIQUID ASSETS Cash not in Financial Institution Amount: __________ Location of Cash not in Financial Institution: __________ __________ __________ __________ __________ __________ __________ CASH IN BANK OR AT FINANCIAL INSTITUTION Balance at Bank/Financial Commencement Institution Account No. Type of Action __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Total Bank Accounts __________ - 2 - FEDERAL/STATE/CITY/MUNICIPALITY OR OTHER GOVERNMENT SECURITY OR OBLIGATION Current Maturity Description Location Value Date __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ SECURITIES PUBLICLY TRADED Financial Market Valuation Description # of Shares Institution Value Method __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ SECURITIES NOT PUBLICLY TRADED Financial Market Valuation Description # of Shares Institution Value Method __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ - 3 - OTHER INVESTMENTS Description Value Valuation Method __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ NOTES, ACCOUNTS RECEIVABLE (include description & reason for loan) Debtor Description Balance Loan Date Due Name 1. __________ ____ ____ ____ ____ ____ ____ ____ 2. __________ ____ ____ ____ ____ ____ ____ ____ LIFE INSURANCE Face Insured Company Policy Number Value __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ - 4 - Cash Value Loan Amount Beneficiary __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ - 5 - REAL ESTATE 1. Homestead: __________ __________ __________ Address: __________ __________ __________ __________ Legal Description: Lot __________ Block __________ Subdivision __________ __________ __________ __________ Other Description __________ __________ __________ __________ __________ __________ __________ __________ Market value $ __________ , based upon (tax assessment/ formal appraisal by __________ other/ __________ ) Subject to the following encumbrance(s): Contract for deed with __________ , balance $ __________ First Mortgage with __________ , balance $ __________ Second Mortgage with __________ , balance $ __________ Equity Loan with __________ , balance $ __________ Improvement Loan __________ , balance $ __________ Title held in name(s) of: __________ __________ __________ Mortgagees Phone #: __________ __________ __________ 2. Other Real Estate: __________ __________ __________ Address: __________ __________ __________ __________ Legal Description: Lot __________ Block __________ Subdivision __________ __________ __________ __________ Other Description __________ __________ __________ __________ __________ __________ __________ __________ Market value $ __________ , based upon (tax assessment/ formal appraisal by __________ other/ __________ ) - 6 - Subject to the following encumbrance(s): Contract for deed with __________ , balance $ __________ First Mortgage with __________ , balance $ __________ Second Mortgage with __________ , balance $ __________ Equity Loan with __________ , balance $ __________ Improvement Loan __________ , balance $ __________ Title held in name(s) of: __________ __________ Mortgages Phone #: __________ __________ __________ 3. Other Real Estate: __________ __________ __________ Address: __________ __________ __________ __________ Legal Description: Lot __________ Block __________ Subdivision __________ __________ __________ __________ Other Description __________ __________ __________ __________ __________ __________ __________ __________ Market value $ __________ , based upon (tax assessment/formal appraisal by __________ other/ __________ ) Subject to the following encumbrance(s): Contract for deed with __________ , balance $ __________ First Mortgage with __________ , balance $ __________ Second Mortgage with __________ , balance $ __________ Equity Loan with __________ , balance $ __________ Improvement Loan __________ , balance $ __________ DEFERRED COMPENSATION PLANS How many years to retirement and/or distribution __________ - 7 - DEFINED BENEFIT PLAN Plan Name: __________ Plan #: __________ Plan Administrator: __________ % of Vesting: __________ Number of Years to 100% Vesting: __________ Present Value: __________ Funds Location: __________ __________ __________ __________ Valuation Method: __________ __________ __________ __________ DEFINED CONTRIBUTION PLAN Plan Name: __________ Plan #: __________ Plan Administrator: __________ % of Vesting: __________ Number of Years to 100% Vesting: __________ Present Value: __________ Funds Location: __________ __________ __________ __________ Valuation Method: __________ __________ __________ __________ IRA'S Location of Funds: __________ Account #: __________ Present Value: __________ Maturity Date: __________ Rate of Interest __________ __________ SEP's or KEOUGH's Location of Funds: __________ Account #: __________ Present Value: __________ Plan Administrator: __________ Loans: __________ __________ __________ __________ __________ - 8 - PERSONAL PROPERTY Automobiles and/or Trucks Make, Model and Year: __________ __________ __________ Current Amount Financing: __________ __________ __________ Loan Financing: __________ __________ __________ Current Value: __________ __________ __________ Valuation Method: __________ __________ __________ __________ Automobiles and/or Trucks Make, Model and Year: __________ __________ __________ Current Amount Financing: __________ __________ __________ Loan Financing: __________ __________ __________ __________ Current Value: __________ __________ __________ __________ Valuation Method: __________ __________ __________ Recreational Vehicles (Boats, Bicycles, Motorcycles, Snowmobiles, etc.) Make, Model and Year: __________ __________ __________ Current Amount Financing: __________ __________ __________ Loan Financing: __________ __________ __________ __________ Current Value: __________ __________ __________ __________ Valuation Method: __________ __________ __________ __________ Make, Model and Year: __________ __________ __________ __________ Current Amount Financing: __________ __________ __________ Loan Financing: __________ __________ __________ __________ - 9 - Current Value: __________ __________ __________ __________ Valuation Method: __________ __________ __________ __________ HOUSEHOLD GOODS AND FURNISHINGS Description Value Location Method of Valuation __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ v JEWELRY Purchase Date of Insured Market Method of Description Price Purchase Value Value Valuation __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ __________ _____ _______ _______ _______ _______ OTHER PROPERTY List any items with a value of $300 or more, including but not limited to, antiques, heirlooms, guns, stereo equipment, televisions & video equipment, collections or furniture: Basis for Description Value Value Claimed Location __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Other items, attach schedules as necessary. - 10 - MISCELLANEOUS PROPERTY Patents, Trademarks, Copyrights and Royalties Description Value __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ OWNED BUSINESS INTERESTS SOLE PROPRIETORSHIPS Proprietorship Name: __________ __________ __________ Business Location: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Type of Business: __________ __________ __________ __________ % of Ownership: __________ Years Established: __________ Last Year Tax Return Filed: __________ Value (est.) __________ Valuation Method: __________ __________ __________ __________ Buy-Sell Agreements: Yes No PARTNERSHIP - General or Limited (specify) Partnership Name: __________ __________ __________ __________ Business Location: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Type of Business: __________ __________ __________ __________ % of Ownership: __________ Years Established: __________ Last Year Tax Return Filed: __________ Value (est.) __________ Valuation Method: __________ __________ __________ __________ Buy-Sell Agreements: Yes No CORPORATIONS - Sub S OR C (specify) Name: __________ __________ __________ __________ __________ Business Location: __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Type of Business: __________ __________ __________ __________ % of Ownership: __________ __________ __________ Years Established: __________ Last Year Tax Return Filed: __________ Value (est.) __________ Valuation Method: __________ __________ __________ __________ Buy-Sell Agreements: Yes No - 11 - TRUSTS Name of Name of Value of Beneficiary's Beneficiary Trustee Trust Interest in Trust 1. __________ __________ __________ __________ __________ 2. __________ __________ __________ __________ __________ 3. __________ __________ __________ __________ __________ 4. __________ __________ __________ __________ __________ PERSONAL PROPERTY HELD FOR YOU BY ANOTHER (Including cash and negotiable securities) Person Description Holding Title To Value Encumbrance __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ NON-MARITAL PROPERTY Description Date Non-Marital Sources of Acquired Value Non-Marital Interest __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ - 12 - __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ LIABILITIES Debts (Credit cards) Creditor's Responsible Balance as of Payment Per Name Party Commencement Date Month __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ Dated: Petitioner/Respondent Subscribed and sworn to before me this _____ day of ____________, 20___. _______________________________ NOTARY PUBLIC - 13 -

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