1 Client's Name Multi-Door Number ASSETS Please attach documentation Real Estate (Please attach appraisals, current mortgage statements) Property 1 - Address: Property 2 - Address: Purchase Price $ Purchase Price $ Purchase Date Purchase Date Current Value $ Current Value $ Outstanding Mortgage $ Outstanding Mortgage $ Other liens $ Other liens $ Estimated Equity $ Estimated Equity $ Name(s) on Title: Name(s) on Title: oHusband oWife oBoth oHusband oWife oBoth oOther oOther Name(s) on Mortgage: Name(s) on Mortgage: oHusband oWife oBoth oHusband oWife oBoth oOther oOther Name(s) on other Liens: Name(s) on other Liens: oHusband oWife oBoth oHusband oWife oBoth oOther oOther Bank Accounts (Please attach current statements) Name Type Name(s) Current Account (last 4 of Bank of Account on Account Balance (& date) Number digits) American LegalNet, Inc. www.FormsWorkFlow.com 2 Pensions/Retirement Plans (Please attach plan statements, current personal benefits statements) Type of Plan Name of Plan Individual Current Value (& date) Covered IRAs (Please attach current statements) Type Institution Individual Current Value (& date) Covered Stocks, Bonds, Notes (Please attach current statements) Name of Instrument Type (and # of shares) Estimated Value (& date) Life Insurance (Please attach current statements) Name of Plan Type of Plan Individual Beneficiaries Face Value Current (term, whole Covered by Value life, etc.) Plan Business Or Professional Interests (Please attach appraisals, valuations) Type of Interest Estimated Value American LegalNet, Inc. www.FormsWorkFlow.com 3 Automobiles (Please attach blue book values, current statements of liens) Model &Year In Whose In Whose Estimated Lien Possession Name Value Personal Property (Please attach supporting documentation for estimated values, such as receipts or appraisals, and current statements of liens. Attach list if necessary.) Property In Whose In Whose Estimated Lien Possession Name Value Inheritance Or Trust Fund (Please attach current statements) From Whom To Whom Property Effective Estimated Date Value Other Assets (Please attach appraisals, current statements of liens) Type In Whose Estimated Lien Possession Value American LegalNet, Inc. www.FormsWorkFlow.com 4 LIABILITIES / DEBTS Please attach documentation Real Estate - Property 1 Address: Outstanding Mortgage (Please attach current statement and check off below what is included in the payment): Principal Interest Property Taxes Insurance Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) 2nd Trust/Home Equity Line(s) (Please attach current statements) Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) Other Lien(s) on Property (Please attach current statements) Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) Real Estate - Property 2 Address: Outstanding Mortgage (Please attach current statement and check off below what is included in the payment): Principal Interest Property Taxes Insurance Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) American LegalNet, Inc. www.FormsWorkFlow.com 5 2nd Trust/Home Equity Line(s) (Please attach current statements) Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) Other Lien(s) on Property (Please attach current statements) Company Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) Credit Cards (Please attach current statements) Card Account # In Whose Monthly % Current (last 4 digits) Name(s) Payment Interest Balance (& date) Loans (Please attach current statements of balances due) Creditor In Whose Purpose Terms Current Name(s) Balance (& date) American LegalNet, Inc. www.FormsWorkFlow.com 6 Other Debts (taxes, personal, etc.) (Please attach current statements of balances due) Creditor In Whose Purpose Terms Current Name(s) Balance (& date) SWORN STATEMENT I solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the foregoing paper and that the factual statements made in it are true to the best of my personal knowledge, information and belief. Date Signature American LegalNet, Inc. www.FormsWorkFlow.com 7 EXPENSES / BUDGET Please attach documentation Total Gross Monthly Income $ Payroll Deductions $ Federal Tax $ State Tax $ Local Tax $ FICA $ Retirement $ Health Insurance $ Other: $ $ $ Total Deductions $ Total Net Monthly Income $ Monthly Expenses Housing Rent $ Insurance $ Mortgage (PITI) Principal and Interest $ Property Taxes $ Insurance $ Condo Fee $ Repairs/Maintenance $ Cleaning Service $ Yard Service $ Utilities Electricity $ Telephone $ Water $ Gas $ Fuel Oil $ Cable $ Internet $ American LegalNet, Inc. www.FormsWorkFlow.com 8 Food $ Drug Store Products (do not include prescriptions) $ Clothing $ Transportation Car Payment $ Car Repairs/Maintenance $ Insurance $ Tags $ Gas/Oil $ Parking $ Bus/Metro $ Taxis $ Children's Expenses Child Care $ Babysitting $ School: Tuition $ Books/School Supplies $ Fees (field trips, activities) $ Uniforms $ School lunch $ Transportation $ Tutoring $ Out-of-school Activities: Sports $ Lessons $ Unreimbursed medical expenses: Doctor $ Dentist $ Orthodontist $ Mental Health Professional $ American LegalNet, Inc. www.FormsWorkFlow.com 9 Prescriptions $ Eyeglasses $ Clothing $ Allowance $ Summer Camp/Expenses $ Other: $ $ Medical Expenses Health Insurance (if not taken as deduction from salary) $ Eyeglasses $ Unreimbursed expenses: Doctor $ Dentist $ Mental Health Professional $ Prescriptions $ Insurance (if not taken as deduction from salary) Life $ Disability $ Entertainment (please specify) $ $ $ $ Vacations $ Miscellaneous Cell phone, pager $ Dry Cleaning $ Hair Cuts/Salon $ Gifts $ Dues/Fees $ Newspapers $ Subscriptions $ Contributions $ Other: $ American LegalNet, Inc. www.FormsWorkFlow.com 10 Monthly Payments - Old Debts Closed credit card / store accounts Account pay-off date $ $ $ Student loan $ Outstanding tax bills $ $ Other: $ $ Total Expenses $ Total Remaining (Or Deficit) Monthly $ Revised 9/25/00 American LegalNet, Inc. www.FormsWorkFlow.com