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 -
Valuable tips for finishing your ‘Non Marital Assets’ online
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FAQs
Here is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.
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The best way to complete and sign your non marital assets form
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