STATE OF HAWAI`I FAMILY COURT FIRST CIRCUIT ASSET AND DEBT STATEMENT CASE NUMBER ~ Plaintiff ~ Defendant ~ Both Parties This document is prepared by: FC-CU No. ~ Plaintiff ~ Defendant ~ Atty for Plaintiff ~ Atty for Defendant (Full Name) v. PLAINTIFF Name Address City, State, Zip Code (Full Name) DEFENDANT Telephone Number 1. CASH (on hand or held by others for me): 2. CREDIT UNION ACCOUNTS: Name ~ None ~ $ ~ None . Credit Balance Debt Balance Title (Plaintiff, Defendant, Joint, Other) 3. BANK AND SAVINGS ACCOUNTS: Company & Branch ~ None (Include Trustee Accounts) Title (Plaintiff, Defendant, Joint, Other) Current Balance Type of Account In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. COURT USE ONLY FC Adm 3/13/14 PAGE 1 OF 4 PAGES CUDA ASSET AND DEBT STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI`I FAMILY COURT FIRST CIRCUIT ASSET AND DEBT STATEMENT CASE NUMBER ~ Plaintiff ~ Defendant ~ Both Parties ~ None (Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.) Title (Pltf, Dft, Jt, Other) Date of Acquisition Cost FC-CU No. 4. SECURITIES: Company Market Value Debt Owed 5. VEHICLES: Year ~ None Make (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.) Title (Pltf, Deft, Jt, Other) Current Market Value Debt Owed Against 6. REAL PROPERTY: ~ None Address Title Fee or Date of Lease Acquisition Cost Current Gross Value Total Debt Owed 7. LIFE INSURANCE: Company ~ None Person Insured Face Amount Title Beneficiary (Pltf, Deft, Jt, Other.) Cash Value Debt Owed Against FC Adm 3/13/14 PAGE 2 OF 4 PAGES CUDA ASSET AND DEBT STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI`I FAMILY COURT FIRST CIRCUIT ASSET AND DEBT STATEMENT CASE NUMBER ~ Plaintiff ~ Defendant ~ Both Parties ~None Title (Plaintiff, Defendant, Joint, Other) Type of Plan FC-CU No. 8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS: Employer or Company Years in Plan Total Value 9. ALL OTHER MAJOR ASSETS: General Description (Furniture, Household Effects, Art, Stamps, Coins, Equipment, Tools, Jewelry, Investment Assets, Accounts Receivable, Business Assets, Cemetery Plots or Niches, Tax Refund Due, etc.) Title (Plf, Deft, Jt, Other) Estimated Gross Debt Owed Against ~None 10. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON(S): (Aside from Bank & Savings Accounts Noted in paragraph 3.) Description Trustee(s) Beneficiaries ~None Value Debt Owed Against FC Adm 3/13/14 PAGE 3 OF 4 PAGES CUDA ASSET AND DEBT STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI`I FAMILY COURT FIRST CIRCUIT ASSET AND DEBT STATEMENT CASE NUMBER ~ Plaintiff ~ Defendant ~ Both Parties FC-CU No. 11. ALL OUTSTANDING DEBTS: ~ None (Include those listed in paragraphs 2,4, 5, 6, 7, 9, and 10 above in addition to all Security Mo./Yr. Debt Incurred Total Balance Minimum Monthly Payment charges, finance companies, and personal loans.) Creditor Debtor (Pltf, Deft, Jt, Other) Total Debt in Plaintiff''s Name Alone: Total Debt in Defendant's Name Alone: Total Debt in Joint Names: CERTIFICATION I hereby declare under the penalty of perjury that I have supplied and reviewed the information used in this Asset and Debt Statement and have reviewed this Statement and I certify that the information is accurate, complete, and correct. DATE ~ PLANTIFF'S ~ DEFENDANT'S SIGNATURE DATE ~ PLANTIFF'S ~ DEFENDANT'S SIGNATURE FC Adm 3/13/14 PAGE 4 OF 4 PAGES CUDA ASSET AND DEBT STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com