Fill and Sign the Pennsylvania Cohabitation Form

NON-MARITAL COHABITATION AGREEMENT How to complete this document.Option 1: This document is in Microsoft Word format. You should be able to see fields for completion that are gray shaded areas. If you do not, go on your toolbar to “View”, “Toolbars” and check “Forms”. You should now be able to see the fields. If you do not see a gray box here ( ) you do not have forms checked in the toolbars.Next, read the document and make any changes desired to the text of the document that are not fields.Next, click on the lock in the forms toolbar, or go to “tools”, “protect document” and check “forms” then OK. This will lock the document for completion.You may now complete all the fields on your computer and save the completed form.WARNING: If you lock the document and then complete the fields and then unlock you will lose the information you completed in the fields. Option 2: Make sure you can see the fields. See option 1. Revise the document text. Then click on each field to be completed and type the information you desire. This will replace the field with the information and the field will no longer exist. - 1 - NON-MARITAL COHABITATION AGREEMENT REA D B EFO RE S IG NIN G : I M PO RTA NT N OTIC E: E A CH P A RTY T O T H IS A GREEM EN T AG REES TH AT TH EY H AVE H AD A N O PPO RTU NIT Y TO CO NSU LT W IT H A N ATTO RN EY O F T H EIR C H OIC E L IC EN SE D T O P R A CTIC E L A W IN T H EIR S T A TE O F RE SID EN CE (N OT T H E S A M E A TTO RN EY ) A ND T H AT E A CH P A RTY H AS F U LLY REA D, U NDER ST A ND A ND A GREE T O T H E T E R M S O F T H IS A GREEM EN T. E A CH PA RTY F U RTH ER A GREES T H AT T H EY A RE N OT A CTIN G U NDER D URESS O R U NDUE IN FL U EN CE IN E X EC U TIN G T H IS A GREEM EN T A ND T H AT E X EC U TIO N O F S A M E IS DO NE F R EEL Y A ND V O LU NTA RIL Y . TH IS A GREEM EN T, m ad e th is ___ day of __________________, 20____, betw een _______ _______________ _____, of _____________ ______________ __________________, (" F ir s t Party ”), an d ____ _______________________ , of ___________________________ , __ _____ ___________ , ( " S eco nd P arty ”), W HER EA S, th e partie s now re sid e to geth er or are in co nte m pla tio n of esta b lis h in g a re sid en ce t o geth er; a n dW HER EA S, th e partie s desir e to ex ecu te th is ag re em en t in co nte m pla tio n of sa id co hab ita ti o n, o r i n c o nsid era tio n o f c o ntin ued c o hab ita tio n; a n d W HER EA S, th e p artie s d esir e to en te r in to an ag re em en t re g ard in g certa in p ro pertie s, re sp onsib ilitie s, d utie s a n d o blig ati o ns in clu din g, b ut n ot lim ite d to , a n y in te re st, p re se n t o r f u tu re , le g al o r e q uita b le , v este d o r c o ntin g en t, i n r e al o r p ers o nal p ro perty , i n clu din g i n co m e a n d e arn in gs; an dW HER EA S, th e p artie s h av e fu rn is h ed e ach o th er w ith a fin an cia l sta te m en t w hic h e ach party a ck now le d ges is a fu ll a n d c o m ple te d is c lo su re o f s u bsta n tia lly a ll o f th e re al a n d p ers o nal pr o perty n ow o w ned b y h im o r h er. E ach p arty a ck now le d ges th at th e v alu es a re a n e stim ate b y him o r h er o f t h e a p pro xim ate p re se n t v alu e t h ere o f, a ll o f w hic h p ro perty i s n ow a n d s h all c o ntin ue to b e s e p ara te p ro pertie s o f th e re sp ectiv e p artie s, c o pie s o f s a id fin an cia l s ta te m en ts a re a tta ch ed here to a s E xhib its “ A ” a n d “ B ” r e sp ectiv ely ; a n d W HER EA S, th e partie s desir e to ex pre ss in w ritin g th eir ag re em en t th at, ex cep t as he re in afte r s p ecif ic ally p ro vid ed , th eir c o hab ita tio n s h all n ot in a n y w ay c h an ge th eir r ig hts , o r th e rig hts o f t h eir h eir s ( e x clu siv e o f t h e p artie s) o r o f t h eir d ev is e es o r l e g ate es, i n t h e r e al a n d p ers o nal pr o perty o w ned o r h ere afte r a cq uir e d b y e ach o f t h e p artie s a n d t h at s a id r ig hts s h all b e g overn ed b y th e t e rm s o f t h is a g re em en t.N OW , T H ER EFO RE, in co nsid era tio n o f th e p artie s an d o f th eir m utu al p ro m is e s an d ag re em en ts , t h ey a g re e o ne w ith t h e o th er a s f o llo w s:1 . Prev io u sly O wned P ro p erty : E xcep t a s o th erw is e p ro vid ed h ere in , e ach o f th e pa rtie s s h all h av e fu ll c o ntr o l o f th e p ro perty , re al, p ers o nal a n d m ix ed , w here v er lo cate d , o f th e oth er a n d sh all h av e a n d h ere b y is g iv en th e rig ht to le ase , se ll, c o nvey , m ortg ag e o r o th erw is e - 2 - dis p ose o f th e s a m e a n d re ceiv e a ll m onie s, re n ts , is su es, in co m e a n d p ro fits th ere o f w ith out a n y restr ic tio ns w hate v er a n d w ith out i n te rfe re n ce f ro m t h e o th er p arty . F urth er, b oth p artie s w aiv e a n y rig hts w hic h m ay b e e sta b li s h ed b y c o hab ita tio n, e x cep t a s e x pre ssly p ro vid ed f o r i n t h is a g re em en t. Pr o perty acq u ir e d by eith er party prio r to ex ecu tio n of th is ag re em en t th at sh all here afte r be co nsid ere d p ro p erty o f b oth p artie s a n d t h ere fo re j o in t p ro perty i s a s f o llo w s: .2. Deb ts : The p artie s a g re e i n r e fe re n ce t o d eb ts a s f o llo w s:(a ) A s t o D eb ts o f e ith er p arty i n cu rre d p rio r t o c o hab ita tio n: T o b e m utu ally r e sp onsib le f o r s a id d eb ts . T o b e r e sp onsib le f o r t h eir i n div id ual d eb ts o nly . T o j o in tly b e r e sp onsib le f o r o nly t h e f o llo w in g d eb ts : (b ) A s t o d eb ts i n cu rre d b y t h e p artie s a fte r c o hab ita tio n: S uch d eb ts s h all b e t h e r e sp onsib ility o f t h e p art i n cu rrin g s a m e. B oth p artie s s h all b e r e sp onsib le f o r th e d eb ts o f b oth p artie s. T he d eb ts s h all b e co nsid ere d j o in t. T he p artie s s h all o nly b e jo in tly r e sp onsib le f o r jo in t d eb ts a n d e ach p arty s h all be r e sp onsib le f o r t h eir o w n i n div id ual d eb ts . 3 . Wills : T he p artie s h av e e ach e x ecu te d a L ast W ill a n d T esta m en t, c o pie s o f w hic h a re atta ch ed h ere to a s E xhib its “ C ” a n d “ D ”. T he p artie s a g re e th at th ese W ills a re in c o nfo rm ity w ith th e p ro vis io ns o f th is a g re em en t a n d a s c o n sid era tio n fo r th is a g re em en t, e ach p arty d oes h ere b y waiv e a n y a n d a ll o bje ctio n to th e te rm s o f th e s a id L ast W ill a n d T esta m en t o f th e o th er a n d e ach party a g re es n ot to c o n te st o r re n ounce th e te rm s o f th ere o f. L ik ew is e , e ach p arty a g re es n ot to conte st o r re n ounce a n y fu tu re W ills o r C odic ils , w hic h a re in c o nfo rm ity w ith th e te rm s o f th is ag re em en t. T he p artie s s h all n ot c h an ge t h eir e x is tin g W ill, i f a n y, o r m ak e a n ew w ill a t t h is tim e, b ut a n y n ew W ill e x ecu te d s h all b e i n c o nfo rm an ce w ith t h e p ro vis io ns o f t h is a g re em en t. 4 . Evid en ce o f A gree m en t. T he f a ct th at e ith er p arty ( w ith out b ein g o blig ate d to d o so ) m ay g iv e, d ev is e o r b eq ueath to th e o th er p arty p ro perty o r a n in te re st th ere in , o r o th erw is e co nfe r rig hts o r p ow ers o n th e o th er p arty , in tr u st o r b y g if t o r w ill, s h all n ot b e c o nstr u ed a s a wa iv er o f a n y p ro vis io n h ere o f o r a s e v id en ce th at th ere is o r w as a n a g re em en t o r u nders ta n din g betw een t h e p artie s o th er t h an a s s p ecif ic ally e x pre sse d h ere in .5. Execu tio n o f D ocu m en ts : E ach p arty a g re es, o n b eh alf o f h im se lf o r h ers e lf a n d o f his o r h er h eir s , e x ecu to rs , a d m in is tr a to rs a n d a ssig ns, t h at h e, s h e o r t h ey , a t t h e r e q uest o f t h e o th er pa rty o r th e la tte r's h eir s , e x ecu to rs , a d m in is tr a to rs a n d a ssig ns ( b ut a t th e c o st o f th e o th er p arty o r his o r h er h eir s , e x ecu to rs , a d m in is tr a to rs , a n d a ssig ns), w ill m ak e, d o, e x ecu te , a ck now le d ge a n d deliv er an y an d all su ch fu rth er o r o th er acts , d eed s an d in str u m en ts as sh all b e ap pro pria te , - 3 - necessa ry o r d esir a b le t o c a rry i n e ffe ct t h e i n te n t, p urp ose a n d p ro vis io ns o f t h is a g re em en t w ith out qu estio n o r d ela y , e x cep t th at n eith er p arty s h all b e o blig ed to s ig n a n y m ortg ag e, n ote , b ond o r oth er in str u m en t w hic h m ay su bje ct h im o r h er, o r h is o r h er esta te an d p ro perty , to p ers o nal li a b ility .6. Pro p erty a n d D is p osit io n o f P ro p erty : A sse ts acq uir e d b y th e p artie s d urin g co hab ita ti o n s h all b e a cq uir e d i n t h e n am e o r n am es o f t h e p artie s w ho w ill o w n s a m e. A ll p ers o nal pr o perty lo cate d in th e re sid en ce o f th e p artie s s h all b e c o nsid ere d e q ually o w ned b y th e p artie s ex cep t ite m s o w ned p rio r to c o hab it a tio n, o r ite m s a cq uir e d b y in herita n ce o r g if t to o nly o ne p arty . Un le ss o w ned in b oth n am es a ll p ro perty s h all b e c o nsid ere d th e p ro perty o f th e p arty in w hose na m e t h e p ro perty i s t itle d . I n s e llin g , a ssig nin g, g ra n tin g, r e le asin g, c o nvey in g o r o th erw is e d ealin g with th e p ro perty o f e ith er p arty , th e p ro perty o f o ne p arty sh all n ot b e so ld , a ssig ned , re le ase d , co nvey ed , o r o th erw is e d is p ose d o f w ith out t h e e x pre ss w ritte n c o nse n t o f t h e p ro perty ’s o w ner. 7. Expenses: The parties agree to share the following expenses as provided below. “Both” means that the expenses will be shared equally. First PartySecond PartyBoth HousingTelephoneResidential GasElectricityCableInternetGroceriesAuto Payments (First Party)Auto Payments (Second Party)Health InsuranceDental InsuranceHealth ExpenseDental ExpenseOther: The parties shall be solely liable or accountable for the following expenses which they may incur or be otherwise accountable for: Child support for any children not of this relationship, child care for any child not of this relationship, magazine subscriptions, health club memberships, food eaten outside the residence when other cohabitant party is not present, food for any third party, medical - 4 - care for any third party, dental care for any third party, traffic fines and costs, tax penalties and liabilities, entertainment expenses for any third party, or entertainment expenses when both cohabitants are not present, legal expenses, personal hygiene or personal care expenses including but not limited to beauty shops, barbershops, health spas, nail care salons, private nursing care, personal trainers, therapists, gambling expenses, alcoholic beverages, tobacco products, toiletry items, vacation expenses when other cohabitant is not present, any expense of guest of other cohabitant, any travel expense including but not limited to travel tickets, motels, hotels, rental cars, charge upon any credit card, bank loans not jointly signed, gifts, or tips for any expenditure, care, maintenance or entertainment for any friend or relative.8.Bank Accounts: The parties agree to the following: (C heck a ll t h at a p ply ). Th e p artie s s h all d ep osit e arn in gs a n d o th er fu nds in jo in t c h eck in g a n d/o r sa v in gs a cco unts , f o r d is p ositio n a t w ill b y e ith er p arty . E ach party shall retain his or her own earnings and other funds in his or her own individual savings, checking, or other account, for disposition at will, except for funds needed for household expenses, if so indicated in this agreement. The parties shall maintain a joint checking account for household expenses such as rent, food, household supplies, and utilities. The parties shall contribute to this account the amounts necessary to cover the household expenses. 9.Health Insurance. Both parties hereby agree that: Both parties will make every reasonable effort to include the other party on any health insurance that might be provided by an employer, equally dividing the cost of said health insurance. The parties will be individually responsible for their own health insurance. 10.Life Insurance. The parties agree that: The parties will make every reasonable effort to name each other as the beneficiary of any life insurance policies held. The parties will not name each other as beneficiaries for any life insurance policies held. 11. Health Care Decisions. The parties agree that: Each party shall execute a durable power of attorney for the purposes of health care decisions in favor of the other party. The parties will not be entitled to make health care decisions for one - 5 - another. 12 . Post-C oh ab it a tio n S upport: Regardless of the length of the period of cohabitation, neither party hereto shall be entitled to any claim for maintenance, alimony, palimony or any other payment based on a claim that the cohabitation inferred, granted, created, or inferred that said right or claim would be created by said cohabitation, except as provided herein. Further both of the parties hereto, hereby agree to indemnity and hold harmless, the other party from any such claim, and against any court costs or attorney fees associated with any claim in contravention of this agreement.The p artie s a g re e th at in th e e v en t o f th e d is so lu tio n o f th e r e la tio nsh ip a n d th e te rm in atio n of c o hab it a tio n: Neither party shall have any obligation to support the other party, either during the relationship or in the event that the relationship terminates. The parties agree that in the event of a separation and an end to cohabitation of the parties, shall pay to , the amount of $ per month for a period of months. 13. Post-C oh ab it a tio n P ro vis io n s: T he partie s fu rth er ag re e th at in th e ev en t of se p ara tio n an d th e en d of co h ab ita tio n, th e fo llo w in g ad ditio nal pro vis io ns sh all ap ply no tw ith sta n din g t h e o th er p ro vis io n s o f t h is a g re em en t: ( C heck a n y t h at a p ply ). , s h all b e e n title d t o r e ceiv e t h e f o llo w in g p ro perty : . , s h all b e e n tit le d t o r e ceiv e t h e f o llo w in g p ro perty : . T he fo llo w in g p ro perty s h all b e s o ld a n d th e p ro ceed s, le ss e x pen se s d iv id ed eq ually b etw ee n t h e p artie s: [ n one o r l is t p ro perty ]: . 1 4. Con tr o llin g L aw : This ag re em en t sh all be co ntr o lle d , co nstr u ed an d giv en effe ct b y a n d u nder th e la w s o f th e S ta te o f P en nsy lv an ia . It is th e in te n t o f th e p artie s th at th e Ag re em en t b e e n fo rc ed to th e f u lle st e x te n t p erm is sib le u nder a p plic ab le la w s a n d p ublic p olic ie s. Th e in valid ity , ille g ality , o r u nen fo rc eab ility o f a n y p artic u la r p ro vis io n o f th is A gre em en t s h all n ot af fe ct th e o th er p ro vis io ns, a n d th is A gre em en t s h all b e c o nstr u ed in a ll r e sp ects a s if s u ch in valid , il l e g al, o r u nen fo rc eab le p ro vis io n h ad b een o m itte d . 1 5 . Entir e A greem en t: This A gre em en t c o nstitu te s th e e n tir e a g re em en t b etw een th e pa rtie s p erta in in g to its su bje ct m atte r a n d it su pers e d es a ll p rio r c o nte m pora n eo us a g re em en ts , re p re se n ta tio ns a n d u nders ta n din gs o f th e p artie s. N o s u pple m en t, m odif ic atio n o r a m en dm en t o f th is A gre e m en t s h all b e b in din g u nle ss e x ecu te d i n w ritin g b y a ll p artie s.1 6 . Waiv er: No w aiv er o f a n y p ro vis io n o f th is A gre em en t s h all b e d eem ed , o r sh all co n stitu te , a w aiv er o f an y o th er p ro vis io n, w heth er o r n ot sim ila r, n or sh all an y w aiv er co nstitu te a c o n tin uin g w aiv er. N o w aiv er s h all b e b in din g u nle ss e x ecu te d in w ritin g b y th e p arty mak in g t h e w aiv er. - 6 - 17 . Bin din g E ffe ct: This A gre em en t s h all b e b in din g u pon th e p artie s h ere to a n d up on t h eir r e sp ectiv e e x ecu to rs , a d m in is tr a to rs , l e g al r e p re se n ta tiv es, s u ccesso rs , a n d a ssig ns.1 8 . Am en dm en t: This ag re em en t m ay only be am en ded or re v oked by w ritte n am en dm en t s ig ned b y b oth p artie s.1 9 . Rep rese n ta tio n : Each p arty f u rth er a g re es a n d a ffir m s a s f o llo w s: (a ) That t h e p arty d id e x ecu te t h e a g re em en t v olu nta rily ; a n d(b ) That t h is a g re em en t i s n ot u nco nsc io nab le w hen i t w as e x ecu te d ; a n d(c ) Both p artie s w ere p ro vid ed p rio r t o e x ecu tio n o f t h is a g re em en t a f a ir a n d r e aso nab le dis c lo su re o f t h e p ro perty o r f in an cia l o blig atio ns o f t h e o th er p arty ; (d ) Both p artie s h ad th e o pportu nity to co nsu lt w ith co unse l p rio r to ex ecu tin g th is do cu m en t. 2 0 . Marria ge: The parties make no promise, contract or agreement, one to another, that this cohabitation will result in marriage. 21.Children: Any rights and obligations of the parties relating to children of the parties, if any, shall be governed by separate agreement and the laws of the State of Pennsylvania. IN W IT N ESS W HER EFO RE, th e partie s here b y ex ecu te th is ag re em en t in se v era l co unte rp arts , a n y e x ecu te d c o py o f w hic h s h all b e c o nsid ere d f o r a ll p urp ose s a s a n o rig in al, o n th e da y a n d y ear a b ove w ritte n . ___________________________________FIRST PARTY _ ___________________________________ SECOND PARTY - 7 - STATE OF _____________________COUNTY OF _____________________ On this, the _________ day of _____________________ , _______, before me _______________________________________, the undersigned officer, personally appeared _______________________________________, known to me (or satisfactorily proven) to be the person whose name _____________________________ subscribed to the within instrument, and acknowledged that _______ (he/she/they) executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. ______________________________Notary PublicPrinted Name: __________________ My Commission Expires: __________________STATE OF _____________________COUNTY OF _____________________ On this, the _________ day of _____________________ , _______, before me _______________________________________, the undersigned officer, personally appeared _______________________________________, known to me (or satisfactorily proven) to be the person whose name _____________________________ subscribed to the within instrument, and acknowledged that _______ (he/she/they) executed the same for the purposes therein contained. In witness whereof, I hereunto set my hand and official seal. ______________________________Notary PublicPrinted Name: __________________ My Commission Expires: __________________ Financial Statement page - 8 - Initials: ________ Exhibit “A” PERSONAL FINANCIAL DISCLOSURE STATEMENT ****************************************************** To: Date: Individual InformationName: Address: City: State:''Zip Occupation: Phone: Current AssetsCurrent LiabilitiesCash on Hand or in Banks Notes Payable (Secured)(Schedule F) Other Cash: Notes Payable (Unsecured)(Schedule G) Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H) Residence Auto Loans (Schedule I) Motor Vehicles (Schedule B) Unpaid Taxes and Interest US Government Securities (Schedule C) Due to Brokers Non-Marketable Securities (Schedule D) Open Accounts Stocks (Schedule E) Credit Cards (List): Other Personal Property Life Insurance Cash Value Business Interests Notes Receivable Other Assets:Other: Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES Total Assets NET WORTH Individual Income Information (Annual)Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent Liabilities Contingent LiabilitiesGuarantor, Co-maker Guarantor or Co-Maker Lease or Contracts Lease or Contracts Legal Claims Legal Claims Other: Other: Financial Statement page - 2 - Initials: ________ SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ $ SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) $ $ $ $ $ $ SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) $ $ $ $ $ $ We/I Certify this Statement to be true and correct as of the date indicated:_________________________________Signature Financial Statement page - 4 - Initials: ________ Exhibit “B” PERSONAL FINANCIAL DISCLOSURE STATEMENT ****************************************************** To: Date: Individual InformationName: Address: City: State:''Zip Occupation: Phone: Current AssetsCurrent LiabilitiesCash on Hand or in Banks Notes Payable (Secured)(Schedule F) Other Cash: Notes Payable (Unsecured)(Schedule G) Real Estate (other than residence Schedule A) Real Estate Mortgages Payable (Schedule H) Residence Auto Loans (Schedule I) Motor Vehicles (Schedule B) Unpaid Taxes and Interest US Government Securities (Schedule C) Due to Brokers Non-Marketable Securities (Schedule D) Open Accounts Stocks (Schedule E) Credit Cards (List): Other Personal Property Life Insurance Cash Value Business Interests Notes Receivable Other Assets:Other: Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES Total Assets NET WORTH Individual Income Information (Annual)Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent Liabilities Contingent LiabilitiesGuarantor, Co-maker Guarantor or Co-Maker Lease or Contracts Lease or Contracts Legal Claims Legal Claims Other: Other: Financial Statement page - 2 - Initials: ________ SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Financial Statement page - 3 - Initials: ________ SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) $ $ $ $ $ $ SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) $ $ $ $ $ $ SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) $ $ $ $ $ $ We/I Certify this Statement to be true and correct as of the date indicated:_________________________________Signature