VERIFIED PERSONAL FINANCIAL STATEMENT County Case No. Social Security No.: Phone: Name: Address: EACH PARTY MUST PROVIDE THE OTHER WITH A COMPLETED COPY OF THIS VERIFIED PERSONAL FINANCIAL STATEMENT WITHIN TWENTY ONE (21) DAYS AFTER DEFENDANT FILES THIS FIRST RESPONSIVE PLEADING OR APPEARANCE (STATEMENT NOT REQUIRED IF DEFENDANT FILES NOTHING WITH COURT CLERK). THIS STATEMENT IS NOT IN PLACE OF OTHER DISCOVERY, AND PROVIDING THE STATEMENT DOES NOT LIMIT OTHER DISCOVERY PERMITTED BY LAW. DO NOT FILE THIS STATEMENT WITH THE COURT CLERK. The following is being submitted by me as a true and accurate statement of my financial condition on: Total of Assets and Liabilities (complete all schedules attached and insert totals below) 1. 2. 3. 4. 5. 6. 7. 8. 9. Bank and Credit Union Accounts Real Estate (Net Equity) Investments: Retirement Plans Life Insurance Motor Vehicles Personal Property Other Assets Spouse Assets $ $ $ $ $ $ $ $ $ TOTAL ASSETS 10. Credit Card Debts 11. Other Debts $ $ $ TOTAL LIABILITIES $ $ NET WORTH (TOTAL ASSETS LESS LIABILITIES) The foregoing personal financial statement and following attachments have been carefully read, and I hereby declare, verify and certify that to the best of my knowledge, information and belief the same is a full and correct exhibit of my personal financial condition. I UNDERSTAND THAT FAILURE TO INCLUDE ALL ASSETS MAY RESULT IN FORFEITURE OF SUCH ASSETS OR OTHER LEGAL SANCTIONS. Dated: ___________________________________________________ Name: ____________________________________________________ Name: Attorney for Signatory American LegalNet, Inc. www.FormsWorkflow.com Personal Financial Statement of Page 2 The following schedules are an integral part of the financial statements: Income and Employment Information Name and Address of employer: Occupation and type of business: Position: Years with Employer: Gross (pre-tax) income for prior year: Gross (pre-tax) income year to date: Portion overtime/bonus: Other Income (Itemize): Assets and Liabilities Include all of your accounts or assets and joint accounts or assets held with your spouse or others, and indicate for each if item is joint (J) or individual (I). All items in the sole name of your spouse are to be listed separately. Attach supplements as necessary. Use whole dollar amounts. 1. Bank and Credit Union Accounts. List checking, savings, certificates of deposit, other. (For each account include the name of the bank, credit union or other financial institution, name/s on the account, and amount of the account). Total: $ American LegalNet, Inc. www.FormsWorkflow.com Personal Financial Statement of Page 3 2. Real Estate. List address, name/s on title, state equalized value (SEV), appraised value (if known), mortgage balance due, home equity loan balance due, lender/s, any other liens or conditions affecting value. Total: $ 3. Investments. List all stocks, stock options (vested or unvested), bonds, mutual funds, marketable securities, limited partnership personal property of any nature, including name/s on title and current market value. Total: $ 4. Retirement Plans. List all pension, profit-sharing, individual retirement accounts (IRAs), 401(k) or other deferred compensation accounts, Keogh or SEP (self-employed plans), or other similar assets, providing employer, account name, custodian, and amount of total account or periodic benefit. Total: $ 5. Life Insurance. List all policies by insurer, amount of death benefit, owner, cash value and beneficiary. Include amounts provided by employer and so indicate: Total: $ American LegalNet, Inc. www.FormsWorkflow.com Personal Financial Statement of Page 4 6. Motor Vehicles. List all cars, boats, motorcycles or other motorized transport, with name/s on title, date and cost of purchase, present value, loan balance and lender. Total: $ 7. Personal Property. List personal effects and household goods and furnishings with item value over $500. For example, works of art, antiques, jewelry, stamp or coin collections and the like. Total: 8. Other Assets. following: - - - $ List all assets not specifically listed above. Include the All notes receivable, including debtor and amount. Any interest in any business entity, partnership or professional practice (including nature of business and interest, accounts receivable, bank accounts and other assets and value as known); Information property, such as patents, copyrights, and trademarks, royalty agreements; Vested inheritances, including any interest in any trust as income beneficiary, remainderholder, or otherwise (but excluding designation in any will or revocable trust of a living person); Any other asset of any nature known to you in which you have or claim any interest that has or may have value. Total: $ American LegalNet, Inc. www.FormsWorkflow.com Personal Financial Statement of Page 5 9. Assets and Liabilities of Spouse. List all individual assets and liabilities of your spouse held in individual name or jointly with someone other than yourself and not included above. (If unknown or uncertain, provide information in your possession and indicate limitations on information available). Total: $ 10. Credit Card Debts. List all consumer credit not paid in full each month, including creditor, name on account and balance due. Total: $ 11. Other Debts. List all other debts, notes payable, or unpaid taxes. name of creditor and balance due (unless previously listed). Total: Include $ Other Matters. List all other matters known to you that may materially affect your financial condition or the financial condition of the other party, including personal injury claims or worker's compensation claims pending or accrued, lawsuits involving either party, lawsuits involving any business entity in which either party has or claims an interest, bankruptcy proceedings, tax matters, existing support obligations, uninsured medical conditions, and so on. Total: $ American LegalNet, Inc. www.FormsWorkflow.com