Fill and Sign the Regular Claims Hawaii State Judiciary Form

STATE OF HAWAII FAMILY COURT CIRCUIT ASSET AND DEBT STATEMENT Plaintiff Defendant Both Parties CASE NUMBER FC-D NO. _______________________________________ PLAINTIFF (Your Full Name) VS. _______________________________________ DEFENDANT (Your Spouse’s Full Name)This document is prepared by Plaintiff Attorney For Plaintiff Atty. For Defendant_______________________________________Name______________________________________________________________________________Address_______________________________________City, State, Zip_______________________________________Phone1. Cash (on hand or held by others for me) $_______________________________________2.CREDIT UNION ACCOUNTS: Name Title (H, W, J) Credit Balance Debt Balance__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3.BANK AND SAVINGS ACCOUNTS: (Include Trustee Accounts) Company and Branch Type of Account Title (H, W, J) Current Balance________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4.SECURITIES: (Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.) Company Title (H, W, J) Date of Acquisition Cost Market Value Debt Owed Against ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Page 2 5. VEHICLES: (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.) Year Make Title (H, W, J) Current Market Value Debt Owed Against________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________6. REAL PROPERTY: Date of Current TotalAddress Fee or Lease Title (H, W, J) Acquisition Cost Gross Value Debt Owed________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________7. LIFE INSURANCE: Title Debt Owed Company Person Insured Face Amount Beneficiary (H, W, J) Cash Value Against______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS: Total Employer or Company Title (H, W, J) Type of Plan Years in Plan Value______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________9. ALL OTHER MAJOR ASSETS: (Furniture, Household Effects, Art, Stamps, Coins, Tools, Equipment, Jewelry, Accounts Receivable, Investment Assets, Business Assets, Cemetery Plots or Niches, Tax Refunds Due, etc.)General Description Title (H, W, J) Estimated Gross Value Debt Owed Against________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Page 310. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON/S: (Aside from Bank & Savings Accounts Noted in paragraph 3) Descriptions Trustee/s Beneficiaries Value Debt Owed Against________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________11.ALL OUTSTANDING DEBTS: (Include those listed parts in 2, 4, 5, 6, 7, 9, and 10 above, in addition to all credit cards, charges, finance companies, and personal loans.) Debtor Mo./Yr. Total Minimum MonthlyCreditor (H, W, J or Other) Security Debt Incurred Balance Owed Payment__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Total Debt in Wife’s Name Alone: _______________________________________ ___________Total Debt in Husband’s Name Alone: _______________________________________________Total Debt in Joint Names: ________________________________________________________ CERTIFICATION I hereby declare under the penalty of perjury that I have supplied the information used in this Asset and Debt Statement and have reviewed this statement and I certify that the information is accurate, completeand correct.DATE PLAINTIFF’S DEFENDANT’S SIGNATURE DATE PLAINTIFF’S DEFENDANT’S SIGNATURE