CASE NUMBER STATE OF HAWAI217I FAMILY COURT 4SECOND CIRCUIT 4PLAINTIFF (Full Name) VS. DEFENDANT (Full Name) This document is prepared by 002 Plaintiff 002 Defendant 002 Atty. for Plaintiff 002 Atty. for Defendant Name Address 4City, State, Zip 4 Phone 41. Cash (on hand or held by others for me) $ 2. CREDIT UNION ACCOUNTS: Name Title (P,D,J) Credit Balance Debt Balance 3. BANK AND SAVINGS ACCOUNTS: (Include Trustee Accounts) Company & Branch Type of Account Title (P,D,J) Current Balance 4. SECURITIES: (Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.) Company Title(P,D,J) Date of Acquisition Cost Market Value Debt Owed Against Form No. 073925 R12/97 ASSET AND DEBT STATEMENT Reprographics () 2C-E-167 Section 508 Certified ASSET AND DEBT STATEMENT FC-D NO.002 Plaintiff 002 Defendant 002 Both Parties CASE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com Page 2 5. VEHICLES: (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.) Year Make 0Title (P,D,J) Currrent Market Value Debt Owed Against 6. /REAL PROPERTY: Date of AcquisitionCurrent Gross ValueTotal Debt Owed Address Fee or Lease Tltle (P,D,J) Cost 7. /LIFE INSURANCE: Title(P,D,J) Debt Owed Against Company Person Insured Face Amount Beneficiary Cash Value 8. /RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS: Total Value Employer or Company Title (P,D,J) Type of Plan Years in Plan 9. /ALL OTHER MAJOR ASSETS: (Furniture, Household Effects, Art, Stamps, Coins, Tools, Equipment, Jewelry, Accounts Receivable, Investment Assets, Business Assets, Cemetary Plots or Niches, Tax Refunds Due, etc.) General Description 0Title (P,D,J) Estimated Gross Value Debt Owed Against Form No. 073925 R12/97 ASSET AND DEBT STATEMENT .Reprographics () 2C-E-167 4 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 10. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON/S: (Aside from Bank & Savings Accounts Noted in paragraph 3) Description Trustee/s Beneficiaries Value Debt Owed Against 11. ALL OUTSTANDING DEBTS: (Include those listed parts 2, 4, 5, 6, 7, 9, and 10 above, in addition to all credit cards, charges, finance companies, and personal loans.) Debtor(P,D,J or Other) Mo./Yr. Debt Incurred TotalBalance Owed MinimumMonthly Payment Creditor Security Total Debt in Plaintiff220s Name Alone: Total Debt in Defendant220s Name Alone: Total Debt in Joint Names: CERTIFICATION I hereby declare under the penalty of perjury that I have supplied 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 002 PLAINTIFF220S 002 DEFENDANT220S SIGNATURE DATE 002 PLAINTIFF220S 002 DEFENDANT220S SIGNATURE Form No. 073925 R12/97 ASSET AND DEBT STATEMENT .Reprographics ( 2C-E-1674 American LegalNet, Inc. www.FormsWorkFlow.com