Fill and Sign the Your Prospective Spouse Should Also Sign the Last Page Acknowledging Form

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: _________ PERSONAL FINANCIAL DISCLOSURE STATEMENT ****************************************************** To: Date: Individual Information Name: Address: City: State: Zip Occupation: Phone: Current Assets Current Liabilities Cash 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 Liabilities Guarantor, Co-maker Lease or Contracts Legal Claims Other: Financial Statement page - 2 - Initials: _________ SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired Totals SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Date Acquired Par Value Market Value Totals SCHEDULE “D” NON MARKETABLE SECURITIES Description Date Acquired Par Value Market Value Totals Financial Statement page - 3 - Initials: _________ SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value Totals SCHEDULE “F” NOTES PAYABLE SECURED Description Date Balance Payment (m/yr) Totals SCHEDULE “G” NOTES PAYABLE UNSECURED Description Date Balance Payment (m/yr) SCHEDULE “H” REAL ESTATE MORTGAGES Description Date Balance Payment (m/yr) Totals SCHEDULE “I” AUTO LOANS Description Date Balance Payment (m/yr) Totals Financial Statement page - 4 - Initials: _________ CERTIFICATION TO FINANCIAL STATEMENT 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 ___________________. _________________________________ Signature Date: ___________________________ I ___________________________________ acknowledge receipt of this financial statement and disclosure. ________________________________________ Signature Date: ___________________________________ Financial Statement page - 1 - Initials: _________ PERSONAL FINANCIAL DISCLOSURE STATEMENT ****************************************************** To: Date: Individual Information Name: Address: City: State: Zip Occupation: Phone: Current Assets Current Liabilities Cash 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 Liabilities Guarantor, Co-maker Lease or Contracts Legal Claims Other: Financial Statement page - 2 - Initials: _________ SCHEDULE “A” REAL ESTATE Description of Real Estate Cost Market Value Date Acquired Totals SCHEDULE “B” MOTOR VEHICLES Description of Motor Vehicles Cost Value Totals SCHEDULE “C” U.S. GOVERNMENT SECURITIES Description of Stock or Bond Date Acquired Par Value Market Value Totals SCHEDULE “D” NON MARKETABLE SECURITIES Description Date Acquired Par Value Market Value Totals Financial Statement page - 3 - Initials: _________ SCHEDULE “E” STOCKS Company Shares Date Acquired Par Value Market Value Totals SCHEDULE “F” NOTES PAYABLE SECURED Description Date Balance Payment (m/yr) Totals SCHEDULE “G” NOTES PAYABLE UNSECURED Description Date Balance Payment (m/yr) SCHEDULE “H” REAL ESTATE MORTGAGES Description Date Balance Payment (m/yr) Totals SCHEDULE “I” AUTO LOANS Description Date Balance Payment (m/yr) Totals Financial Statement page - 4 - Initials: _________ CERTIFICATION TO FINANCIAL STATEMENT 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 ___________________. _________________________________ Signature Date: ___________________________ I ___________________________________ acknowledge receipt of this financial statement and disclosure. ________________________________________ Signature Date: ___________________________________