INSTRUCTIONS JUDGMENT CREDITOR: Complete Name of Case and Docket No., put an "X" in the box next to the items to be answered. PERSON SERVED WITH INTERROGATORIES: Answer the questions indicated by X . You must disclose assets of the judgment debtor up to an amount clearly sufficient to satisfy the judgment indicated by the "Amount Due Thereon" on the attached form JD-CV-23. Place answers in space provided on this form. If you need more room to answer these questions, use the space on page 2 of attached form JD-CV-23 or attach additional sheets. You must answer the questions and return them to the person named on attached form JD-CV-23 within thirty days of the date of service. NAME OF CASE DOCKET NO. I. JUDGMENT DEBTOR STATE YOUR NAME, ADDRESS, AND TELEPHONE NO. X Are you presently employed? NO YES (If yes, complete the information below) NAME, ADDRESS, AND TELEPHONE NO. OF YOUR EMPLOYER YOUR JOB TITLE OR POSITION NAME, ADDRESS OF EACH BOOKKEEPER, PAYROLL CLERK OR OTHER PERSON HAVING RECORDS OF SALARIES OR OTHER SUMS OF MONEY PAID TO YOU BY YOUR PRESENT EMPLOYER IF YOU RECEIVE ADDITIONAL COMPENSATION FOR OVERTIME, STATE (1) RATE OF OVERTIME PAY AND (2) THE AVERAGE NO. OF HOURS OF OVERTIME YOU WORK PER WEEK STATE THE DATE ON WHICH YOU ARE PAID FOR BOTH REGULAR AND OVERTIME WORK Are you receiving any income from any source not disclosed in your answers to the foregoing questions? STATE THE SOURCE(S) OF SUCH INCOME NO YES (If yes, complete the information below) AMOUNT RECEIVED EACH WEEK IF THERE ARE ANY PAYMENTS DUE FROM THE ABOVE SOURCE STATE (1) THE AMOUNT DUE AND (2) NAME AND ADDRESS OF PARTY FROM WHOM IT IS DUE List all banks, savings and loan associations, credit unions or other financial institutions in which you maintain an account of any kind, giving in your answer the following: (You need only disclose assets clearly sufficient to ensure full satisfaction of the judgment with interest and costs.) NAME AND ADDRESS OF INSTITUTION NAME AND ADDRESS OF INSTITUTION NAME IN WHICH ACCOUNT IS HELD NAME IN WHICH ACCOUNT IS HELD ACCOUNT NO. PRESENT BALANCE ($) ACCOUNT NO. PRESENT BALANCE ($) IF JOINT ACCOUNT GIVE NAME AND ADDRESS OF OTHER PERSON(S) IF JOINT ACCOUNT GIVE NAME AND ADDRESS OF OTHER PERSON(S) List all nonexempt personal property in which you have an interest, whether legal or beneficial, which in total value is clearly sufficient to ensure full satisfaction of the judgment with interest and costs, including but not limited to (a) cash on hand, (b) household goods and supplies and furnishings, (c) stamp and/or coin collections and other collections, (d) wearing apparel, (e) jewelry, (f) watches, (g) automobiles, (h) trucks, (i) trailers or other motor vehicles, (j) boats, motors and accessories. As to each such item of property give the precise description and location, the approximate value of such property and whether or not such property is subject to any form of security interest, lien or encumbrance. If so, state the name and address of such holder of a security interest, lien or encumbrance, the nature of the instrument evidencing the same and the amount of the instrument. (If additional space is necessary, attach a separate sheet to this form.) State whether any of your nonexempt personal property is in the hands of a third person. If so, describe the property involved, the person or persons so holding the property, the reason the property is so held and any consideration that may have passed therefor. JD-CV-23a (Page 1 of 2) Rev. 6-2000 2001 © American LegalNet, Inc. List all real estate in your name which in total value is clearly sufficient to ensure full satisfaction of the judgment with interest and costs (where possible give street address). List your accounts receivable which in total value are clearly sufficient to ensure full satisfaction of the judgment with interest and costs giving a) the name of the party, b) the amount owed, and c) the date the debt was incurred. (If additional space is needed, attach a separate sheet to this form.) II. EMPLOYER Is the Judgment Debtor employed by you? YOUR NAME, ADDRESS, AND TELEPHONE NO. NO YES (If yes, complete the information below) EMPLOYEE'S NORMAL WORKING HOURS EMPLOYEE'S GROSS SALARY PER HOUR, WEEK, MONTH, OR YEAR THE DATES ON WHICH EMPLOYEE IS PAID FOR BOTH REGULAR AND OVERTIME WORK NAME, ADDRESS, AND TELEPHONE NO. OF THE BOOKKEEPER, PAYROLL CLERK OR OTHER PERSON WHO DISBURSES EMPLOYEE'S WAGES OR SALARY III. FINANCIAL INSTITUTION Does the Judgment Debtor maintain an account of any kind with your institution? NO YES (If yes, complete the information below. You may disclose only whether you hold funds of the judgment debtor on account and the balance of such funds if so held, up to the amount necessary to satisfy the judgment.) YOUR NAME, ADDRESS, AND TELEPHONE NO. NAME, ADDRESS, AND TELEPHONE NO. OF YOUR INSTITUTION ACCOUNT NO. OF EACH ACCOUNT NAME IN WHICH THE ACCOUNT IS HELD PRESENT BALANCE IN EACH ACCOUNT IF JOINT ACCOUNT, THE NAME AND ADDRESS OF THE OTHER PERSON(S) IV. THIRD PERSON IN POSSESSION OF JUDGMENT DEBTOR'S PROPERTY Are you in possession of nonexempt personal property belonging to the judgment debtor? (If yes, complete the following information.) YOUR NAME, ADDRESS, AND TELEPHONE NO. NO YES DESCRIBE THE PROPERTY, THE REASON YOU ARE HOLDING IT AND ANY CONSIDERATION THAT MAY HAVE PASSED FOR YOUR HOLDING THE PROPERTY. LOCATION OF THE PROPERTY X V. SIGNATURE OF PERSON COMPLETING THIS FORM OR AUTHORIZED AGENT NOTE: Interrogatories served on a judgment debtor shall be signed by such debtor under penalty of false statement. SIGNED (Person completing form or authorized agent) PRINT NAME OF PERSON SIGNING AT LEFT DATE SIGNED JD-CV-23a (Page 2 of 2) Rev. 6-2000 2001 © American LegalNet, Inc.