Fill and Sign the Sworn Statement Form 497312333

STATE OF MINNESOTA DISTRICT COURT COUNTY OF             JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, SWORN STATEMENT OF ASSETS AND LIABILITIES AND , Respondent, STATE OF MINNESOTA ) ) SS. COUNTY OF ) I . I, ______________ , swear under oath that I have an interest in the following property: Item Estimate of Value How Value Determined ____________ $ _________ ____________ ____________ $ _________ ____________ ____________ $ _________ ____________ ____________ $ _________ ____________ II . I further swear under oath that the foregoing is a complete and accurate list of any interests I have in property and that I have not made any significant changes to any of my property interests during the last 18 months except as follows: ________________________________________________________ III. I further swear under oath that I have the following liabilities: Creditor Balance Owed Monthly Payment ____________ $ _________ $ _________ ____________ $ _________ $ _________ ____________ $ _________ $ _________ ____________ $ _________ $ _________ ____________ $ _________ $ _________ ____________ $ _________ $ _________ ____________ $ _________ $ _________ III . I further swear under oath that there have been no significant changes to my liabilities during the last 18 months except as follows: ________________________________________________________ IV . I further swear under oath that my current gross income from all sources is - 2 - $ ______________ per ______________ and that my gross annual income from all sources was $ ______________ for the preceding tax year. I receive no cash, which is not characterized as income for tax purposes except ______________ . V . I understand that my failure to honestly, accurately, and completely disclose income, assets or liabilities may be a fraudulent misrepresentation that would be cause for a redistribution of assets (and/or a predetermination of my (child support) (and) (maintenance) obligations after the dissolution) . FURTHER YOUR AFFIANT SAITH NOT. Dated: _________________________ ____________________________ Name_____ Petitioner/Respondent Dated: Subscribed and sworn to before me this _____ day of _________________ , 20 ____ . _______________________________ NOTARY PUBLIC - 3 -