Fill and Sign the State of Nebraska Including Any Uniform Premarital Agreement Act or Other Applicable Laws

- 1 - PR EM ARIT A L A G REEM EN T REA D BEFO RE SIG NIN G : IM PO RTA NT N O TIC E: EA CH PA RTY TO TH IS AG REEM EN T A G REES T H AT T H EY H AVE H AD A N O PPO RTU NIT Y T O C O NSU LT WIT H A N A TTO RNEY O F T H EIR C H OIC E L IC EN SE D T O P R ACTIC E L A W IN TH EIR S T A TE O F R ESID EN CE (N O T T H E S A M E A TTO RNEY ) A ND T H AT H AVE FU LLY R EA D , U NDER ST A ND A ND A G REE T O T H E T ER M S O F T H IS A G REEM EN T. EA CH P A RTY F U RTH ER A G REES T H AT T H EY A RE N O T A CTIN G U NDER D URESS OR UN DUE IN FL U EN CE IN EX EC UTIN G TH IS AG REEM EN T AND TH AT EX EC UTIO N O F S A M E I S D O NE F R EELY A ND V O LU NTA RIL Y . TH IS A GREEM EN T, m ad e t h is _ ___ d ay o f _ _______________, 2 0____, b etw een _ _ _____ _______________ _____ (N am e), of ______________________________ (A ddre ss), __ _____ ______ (S ta te ) (" fir s t party or W if e "), an d _____________________ (N am e), of __ _____ _______________ ______ (A ddre ss), _____________ (S ta te ) (" se co nd party or Hu sb an d "),W I T N E S S E T H W HER EA S, H usb an d ( c h eck a ll t h at a p ply ): h as p re v io usly b een m arrie d ;has a c h ild o r c h ild re n ;has n ot b een m arrie d ; a n d W if e ( c h eck a ll t h at a p ply ): h as p re v io usly b een m arrie d ;has a c h ild o r c h ild re n ;has n ot b een m arrie d . T he p artie s d esir e t o e n te r i n to t h is a g re em en t p rio r t o t h eir c o nte m pla te d m arria g e. W HER EA S, t h e p artie s h ere to h av e a ccu m ula te d s e p ara te e sta te s; a n dW HER EA S, th e partie s are ab out to co ntr a ct m arria g e an d ex ecu te th is ag re em en t in conte m pla tio n o f m arria g e to b e e ffe ctiv e u pon th eir m arria g e in a cco rd an ce w ith th e la w s o f th e Sta te o f N eb ra sk a, in clu din g a n y U nif o rm P re m arita l A gre em en t A ct, o r o th er a p plic ab le la w s, ad opte d b y t h e S ta te o f N eb ra sk a; a n dW 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 atio 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 fu tu re , - 2 - le g al o r e q uita b le , v este d o r c o ntin gen 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 a n d a g re e th at th e v alu es a re a n e stim ate b y h im o r h er o f th e ap pro xim ate p re se n t v alu e o f th e p ro perty . A ll p ro perty lis te d is n ow a n d sh all c o ntin ue to b e se p ara te p ro pertie s o f th e re sp ectiv e p artie s. O rig in als o r c o pie s o f sa id fin an cia l sta te m en ts a re atta ch ed h ere to a s E xhib its " A " a n d " B "; 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 sp ecif ic ally p ro vid ed , th eir m arria g e sh all n ot in a n y w ay c h an ge th eir rig 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; a n dN 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 ) Each o f th e p artie s s h all h av e f u ll c o ntr o l o f h is o r h er o w n s e p ara te p ro perty , r e al, pe rs o nal a n d m ix ed , w here v er th e p ro perty is lo cate d . E ach o f th e p artie s s h all h av e a n d h ere b y is giv en th e r ig ht to le ase , s e ll, c o nvey , m ortg ag e o r o th erw is e d is p ose o f th eir s e p ara te p ro perty a n d receiv 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 re str ic tio ns w hate v er a n d with out in te rfe re n ce fro m th e o th er p arty . Each o f th e p artie s sh all p ay h is o r h er o w n d eb ts wh en ev er c o ntr a cte d a n d i n n o c ase s h all e ith er p arty b e h eld l ia b le f o r t h e d eb ts o f t h e o th er p artie s in a n y w ay . ( 2 ) Excep t as oth erw is e ex pre ssly pro vid ed , each of th e partie s here b y w aiv es, re lin quis h es, c o nvey s, q uitc la im s, b ars , d is c h arg es, su rre n ders a n d re le ase s, a n d h ere b y a g re es to waiv e, re lin quis h , c o nvey , q uitc la im , b ar, d is c h arg e, s u rre n der a n d re le ase , to th e o th er a ll o f th e fo llo w in g: (a ) Any a n d a ll o f h is o r h er r ig ht, t itle a n d i n te re st o f e v ery k in d a n d d esc rip tio n, w hic h he o r s h e m ay h av e, a cq uir e , e n jo y o r b e s e iz ed b y re aso n o f, o r o n o r a fte r, th eir m arria g e, a s th e wif e , h usb an d, w id ow o r w id ow er o f th e o th er p arty , in th e se p ara te p ro perty o f th e o th er p arty , wh eth er r e al, p ers o nal a n d m ix ed a n d w here v er l o cate d ; a n d(b ) Any a n d a ll r ig hts to a n y p ro perty o f th e o th er p arty title d in th at o th er p artie s s o le na m e, w heth er b efo re o r a fte r t h e m arria g e; a n d(c ) Any a n d a ll p ro perty a cq uir e d b y t h e o th er p arty b y i n herita n ce o r o th er m ean s; a n d(d ) Any a n d a ll rig hts , if a n y, to a ll o r a p ortio n o f th e p ro perty o f th e o th er p arty wh eth er b y w ay o f d ow er, c o urte sy , h om este ad , w id ow 's a llo w an ce, s ta tu to ry s h are o r p ro vis io n, de sc en t, c o m munity p ro perty i n herit a n ce, s u ccessio n o r o th erw is e ; - 3 - (e ) His o r h er r ig ht, i f a n y, g ra n te d t o o r v este d i n h im o r h er, b y s ta tu te o r o th erw is e , t o ren ounce, o r to e le c t to ta k e a g ain st, th e p ro vis io ns o f th e o th er p arty 's w ill o r a n y c o dic il th ere to ; an d (f) His o r h er r ig ht, if a n y, g ra n te d to o r v este d in h im o r h er b y s ta tu te o r o th erw is e to act a s e x ecu to r o r a d m in is tr a to r o f t h e o th er p arty 's e sta te . E xcep t a s o th erw is e e x pre ss ly p ro vid ed , i t i s t h e i n te n t o f t h e p artie s t h at t h is p ara g ra p h s h all be c o nstr u ed s o th at e ach p arty m ay d eal w ith h is o r h er p ro perty a n d a n y tr u st in w hic h h e o r s h e ma y h av e a n in te re st a s if th eir m arria g e h ad n ot ta k en p la ce, a n d o n th e d eath o f e ith er p arty h is o r he r e sta te a n d a n y tr u st in w hic h h e o r s h e m ay h av e a n in te re st w ill b e a d m in is te re d , d esc en d a n d be d is tr ib ute d in e x actly th e s a m e w ay a n d to th e s a m e h eir s , n ex t o f k in , d ev is e es o r le g ate es a s if th e o th er p arty h ad p re d ecease d th e p arty s o d yin g. N oth in g c o nta in ed in th is p ara g ra p h o r in th is ag re em en t, h ow ev er, is in te n ded to p re clu de e ith er p arty f ro m v olu nta rily m ak in g p ro vis io n f o r, o r gr a n tin g p ow ers o r rig hts to , th e o th er p arty in a n d b y th e fo rm ers la st w ill, a c o dic il th ere to o r oth erw is e .(3 ) (c h eck O ne) T he p artie s h av e e a ch 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 are a tta ch ed h ere to a s E xhib its a n d . T he p artie s a g re e th at th ese W ills are 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 nsid era tio n f o r th is ag re em en t, e ac h p arty d oes h ere b y w aiv e a n y a n d a ll o bje ctio n to th e te rm s o f th e sa 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 p arty a g re es n ot to c o nte st o r re n ounce th e te rm s of th ere o f. Lik ew is e , each party ag re es not to co nte st or re n ounce a n y f u tu re W ills o r C odic ils , w hic h a re i n c o n fo rm ity w ith t h e t e rm s o f t h is ag re em en t. I n itia ls i f S ele cte d : _ ______ _ ______ _ O R The 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 th is tim e, b ut a n y n ew W ill e x ecu te d s h all b e in c o nfo rm an ce w ith th e p ro vis io ns o f th is a g re em en t. I n itia ls i f S ele cte d : _ ______ _ ________ (4 ) The fa 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 be q 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 c o nfe r r ig hts o r p ow ers o n the 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 w aiv er o f a n y p ro vis io n h ere o f or 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 d in g b etw een th e p artie s o th er th an a s sp ecif ic all y e x pre sse d h ere in .(5 ) Each 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 h is o r h er h eir s , e x ecu to rs , ad m in is tr a to rs a n d a ssig ns, th at h e, s h e o r th ey , a t th e r e q uest o f th e o th er p arty o r th e la tte r's h eir s , ex ecu to rs , a d m in is tr a to rs a n d a ssig n s ( b ut a t t h e c o st o f t h e o th er p arty o r h is o r h er h eir s , e x ecu to rs , ad 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 d eliv er a n y a n d a ll su ch fu rth er o r o th er a cts , d eed s a n d i n str u m en ts a s s h all b e a p pro pria te , n ecessa ry o r d esir a b le t o c arry i n effe ct th e in te n t, p urp ose a n d p ro v is io ns o f th is a g re em en t w ith out q uestio n o r d ela y , e x cep t th at - 4 - neith er p arty sh all b e o blig ed to sig n a n y m ortg ag e, n ote , b ond o r o th 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 e sta te a n d p ro perty , t o p ers o nal l ia b ility .(6 ) In se llin g, a ssig nin g , g ra n tin g, re le asin g, c o nvey in g o r o th erw is e d ealin g w ith th e pro perty o f e ith er p arty , th e p arty w hose p ro perty is b ein g so d ealt w ith sh all b e a n d h ere b y is co nstitu te d th e o th er p arty 's a tto rn ey -in -fa ct a n d a s s u ch s h all h av e f u ll p ow er in th e n am e o f s u ch oth er p arty o r in th e jo in t n am es o f b oth p artie s to jo in in th e c o nte m pla te d tr a n sa ctio n a n d e x ecu te do cu m en ts to e ffe ct it o n b eh alf o f su ch o th er p arty , in dep en den tly a n d w ith out th e c o nse n t o r pr iv ity o f s u ch o th er p arty , t o t h e s a m e e x te n t a n d a s f u lly a s i f t h eir m arria g e h ad n ot t a k en p la ce.(7 ) Durin g th e c o urs e o f th e m arria g e, a ll p ro perty a cq uir e d b y e ach p arty in th eir o w n nam e s h all b e d eem ed to b e p art o f th eir s e p ara te e sta te a n d b y th e te rm s h ere o f, e ach p arty h ere b y waiv es a n d r e lin quis h es a ll c la im t o t h e s e p ara te e sta te o f t h e o th er. L ik ew is e , a ll p ro perty a cq uir e d durin g t h e m arria g e i n t h e j o in t n am e o f b oth p artie s s h all b e d eem ed t o b e p art o f t h eir j o in t e sta te s an d th ere b y e v id en ce th eir in te n t to g ra n t th e p ow ers a n d rig hts to th e p artie s a s to sa id jo in tly ow ned p ro perty a s i s p ro vid ed t o s p o use s b y o pera tio n o f l a w .(8 ) The p artie s a g re e th at e ach p arty s h all p ro vid e fo r th e p ay m en t o f th eir in div id ual he alth ca re , co nvale sc en ce an d fu nera l ex pen se s o ut o f th eir se p ara te esta te so as n ot to b e a fin an cia l b urd en o n e ach o th er.( 9 ) Desp ite a n y o th er p ro vis io ns o f t h is i n str u m en t, t h is a g re em en t s h all n ot a ffe ct i n a n y way th e p artie s' rig hts , title s, p ow ers , d utie s, d is c re tio ns, im munitie s a n d in te re st in a n y p ro perty ow ned i n j o in t t e n an cy o r e n tir e ty w ith r ig hts o f s u rv iv ors h ip , w hic h t h ey m ay h ere afte r a cq uir e .(1 0) To th e ex te n t perm itte d by la w , th is ag re em en t sh all govern th e rig hts an d ob lig atio n s o f t h e p artie s i n t h e e v en t o f d eath o f e ith er o r b oth p artie s, s e p ara tio n o r d iv orc e.In t h e e v en t o f d iv orc e, t h e p artie s a g re e t h is a g re em en t s h all b e b in din g o n b oth p artie s a n d s h all b e in co rp ora te d i n to a n y d iv orc e d ecre e. ( 1 1) N ot a p plic ab le o r T he p artie s fu rth er a g re e th at in th e e v en t o f d iv orc e, th e fo llo w in g a d ditio nal p ro vis io ns s h all a p ply n otw ith sta n din g t h e o th er p ro vis io ns o f t h is a g re em en t: ( a ) The W if e sh all b e en title d to re ceiv e p ro perty o f H usb an d d esc rib ed as fo llo w s: [n o ne o r l is t p ro perty ](b ) The H usb an d sh all b e en title d to re ceiv e p ro perty o f W if e d esc rib ed as fo llo w s: [n o ne o r l is t p ro perty ](c ) The f o llo w in g p ro perty s h all b e s o ld a n d t h e p ro ceed s, l e ss e x pen se s d iv id ed eq ually b etw een t h e p artie s: [n one o r l is t p ro perty ](d ) The H usb an d s h all p ay a lu m p s u m s e ttle m en t to W if e d esc rib ed a s f o llo w s: [n o ne o r l is t p ro perty ](e ) The W if e s h all p ay a lu m p s u m s e ttle m en t to H usb an d d esc rib ed a s f o llo w s: - 5 - [n one o r l is t p ro perty ](f) The m arita l d om ic ile sh all b e [o ccu pie d b y W if e u ntil h er d eath o r oc cu pie d b y H usb an d u ntil h is d eath o r s o ld a n d t h e p ro ceed s d iv id ed e q ually b etw een H usb an d a n d Wif e .(g ) Both p artie s w aiv e th e rig ht to a lim ony a n d p ro perty s e ttle m en t, e x cep t a s oth erw is e p ro vid ed h ere in .(1 2) This a g re em en t s h all b e c o ntr o lle d , c o nstr u ed a n d g iv en e ffe ct b y a n d u nder t h e l a w s of th e S ta te o f N eb ra sk a. I t is th e in te n t o f th e p artie s th at th e A gre em en t b e e n fo rc ed to th e f u lle st ex te n t perm is sib le under ap plic ab le la w s an d public polic ie s. The in valid ity , ille g ality , or un en fo rc ea b 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 a ffe ct th e o th er p ro vis io ns, an d th is A gre em en t s h all b e c o nstr u ed in a ll re sp ects a s if s u ch in valid , ille g al, o r u nen fo rc eab le pro vis io n h ad b een o m itte d . ( 1 3) This A gre em en t c o n stitu te s t h e e n tir e a g re em en t b etw een t h e p artie s p erta in in g t o i ts su bje ct m atte r an d it su pers e d es all prio r co nte m pora n eo us ag re em en ts , re p re se n ta tio ns an d un ders ta n d in 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 em en t s h all be 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 4) No w aiv er o f a n y p ro vis io n o f t h is A gre em en t s h all b e d eem ed , o r s h all c o nstitu te , a wa iv er o f a n y o th er p ro vis io n, w heth er o r n ot s im ila r, n or s h all a n y w aiv er c o nstitu te a c o ntin uin g waiv er. N o w aiv er s h all b e b in din g u nle ss e x ecu te d i n w ritin g b y t h e p arty m ak in g t h e w aiv er.(1 5) This A gre em en t m ay b e e x ecu te d in a n y n um ber o f c o pie s, e ach o f w hic h s h all b e de em ed a n o rig in al a n d n o o th er c o p y n eed b e p ro duced . A ll p ro nouns a n d a n y v aria tio ns th ere o f sh all b e d eem ed to r e fe r to th e m asc u lin e, f e m in in e, n eu te r, s in gula r o r p lu ra l a s th e id en tity o f th e pe rs o n o r p ers o ns m ay r e q uir e .(1 6) 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 u pon th eir re sp ectiv e ex 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 7) This a g re em en t m ay o nly b e a m en ded o r r e v oked b y w ritte n a m en dm en t s ig ned b y bo th p arti e s.(1 8) 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 n sc 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 to e x ecu tio n o f th is a g re em en t a fa ir a n d reaso nab le d is c lo su re o f t h e p ro perty a n d f in an cia l o blig atio ns o f t h e o th er p arty ;(d ) That he an d sh e did hav e, or re aso nab ly co uld hav e had , an ad eq uate - 6 - kn ow le d ge o f t h e p ro perty a n d f in an cia l o blig atio ns o f t h e o th er p arty .T he p artie s h ere b y e x ecu te th is a g re em en t in se v era l c o unte rp arts , a n y e x ecu te d c o py o f wh ic h s h all b e c o nsid ere d f o r a ll p u rp ose s a s a n o rig in al, o n t h e d ay a n d y ear a b ove w ritte n . ____________________________ F IR ST P A RTY ( “ W IF E ”)_ ____________________________S E C O ND P A RTY ( “ H USB A ND”) A ppro ved :A tto rn ey f o r F ir s t P arty : _ __ ________________________________ A tto rn ey f o r S eco nd P arty : _ ______________________ __________ N ote : T his a g re em en t m ust b e e x ecu te d b efo re a n ota ry p ublic . STATE OF _______________________COUNTY OF _____________________The foregoing instrument was acknowledged before me this _________________ (date) by _________________________ and ___________________. (name of persons).___________________________________Notary Public, State of Printed Name:________________________ Commission Expires: _________________STATE OF _______________________ - 7 - COUNTY OF _____________________The foregoing instrument was acknowledged before me this _________________ (date) by _________________________ and ___________________. (name of persons).___________________________________Notary Public, State of Printed Name:________________________ Commission Expires: _________________ Financial Statement Disclosure Information This financial statement disclosure is for use in connection with a premarital agreement and should be completed accurately and completely. This statement should contain a full disclosure of all your assets and liabilities. You should initial each page and sign the last page. Your prospective spouse should also sign the last page acknowledging receipt.Both persons must complete a separate financial statement and provide it to the other party. Two forms are enclosed, one for each party.This form can be completed in Word or printed and completed by hand.If you require additional space, please attach additional pages for the sections you need to expand. Financial Statement page - 1 - Initials: _________ PE R SO NAL F IN ANCIA L D IS C LO SU RE S T A TEM EN T ****************************************************** 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 Visa Life Insurance Cash Value Business IRA Notes Receivable Other Assets:Other:Personal IRA Antiques Partnership Assets Residential Mortgage Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES NET WORTH Total Assets Individual Income Information (Annual)Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent LiabilitiesGuarantor, Co-maker Lease or Contracts Legal Claims Other: SCHEDULE “A” REAL ESTATEDescription of Real Estate Cost Market Value Date Acquired Financial Statement page - 2 - Initials: _________ Totals SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value Totals SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value Totals SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value Financial Statement page - 3 - Initials: _________ Totals SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) Totals SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) Totals SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) Totals CERTIFICATION TO FINANCIAL STATEMENT Financial Statement page - 4 - Initials: _________ I certify this Statement to be true and correct as of the date indicated; that this financial statement is a full and fair disclosure of my assets; and that I provided a true and correct copy of this financial statement to ___________________________________ on ___________________. _________________________________SignatureDate: ___________________________I _ ________________ __________________ a cknowledge r eceipt o f t his f inancial statement a nd d iscl osure.__ _________________ _____________________ Si gnatureD a te: _ ____________ ______________________ Financial Statement page - 1 - Initials: _________ PE R SO NAL F IN ANCIA L D IS C LO SU RE S T A TEM EN T ****************************************************** 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 Visa Life Insurance Cash Value Business IRA Notes Receivable Other Assets:Other:Personal IRA Antiques Partnership Assets Residential Mortgage Total Liabilities TOTAL OF ALL ASSETS LESS TOTAL OF ALL LIABILITIES NET WORTH Total Assets Individual Income Information (Annual)Salary Bonus Commissions Dividends Rental Income Other Income (List): Total Income Contingent LiabilitiesGuarantor, Co-maker Lease or Contracts Legal Claims Other: SCHEDULE “A” REAL ESTATEDescription of Real Estate Cost Market Value Date Acquired Financial Statement page - 2 - Initials: _________ Totals SCHEDULE “B” MOTOR VEHICLESDescription of Motor Vehicles Cost Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIESDescription of Stock or Bond Date AcquiredPar ValueMarket Value Totals SCHEDULE “D” NON MARKETABLE SECURITIESDescription Date AcquiredPar ValueMarket Value Totals SCHEDULE “E” STOCKSCompanySharesDate AcquiredPar ValueMarket Value Financial Statement page - 3 - Initials: _________ Totals SCHEDULE “F” NOTES PAYABLE SECUREDDescription Date BalancePayment (m/yr) Totals SCHEDULE “G” NOTES PAYABLE UNSECUREDDescription Date BalancePayment (m/yr) SCHEDULE “H” REAL ESTATE MORTGAGESDescription Date BalancePayment (m/yr) Totals SCHEDULE “I” AUTO LOANSDescription Date BalancePayment (m/yr) Totals CERTIFICATION TO FINANCIAL STATEMENT Financial Statement page - 4 - Initials: _________ I certify this Statement to be true and correct as of the date indicated; that this financial statement is a full and fair disclosure of my assets; and that I provided a true and correct copy of this financial statement to ___________________________________ on ___________________. _________________________________SignatureDate: ___________________________I _ ________________ __________________ a cknowledge r eceipt o f t his f inancial statement a nd d iscl osure.__ _________________ _____________________ Si gnatureD a te: _ ____________ ______________________