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Asset And Debt Statement Form. This is a Hawaii form and can be use in Family Court Statewide.
Tags: Asset And Debt Statement, Hawaii Statewide, Family Court
CASE NUMBER
STATE OF HAWAI‘I
ASSET AND DEBT STATEMENT
u Plaintiff u Defendant u Both Parties
FAMILY COURT
_________ CIRCUIT
FC-D NO.
This document is prepared by
u
PLAINTIFF
(Full Name)
Plaintiff
u
Defendant
u
Atty. for Plaintiff
u
Atty. for Defendant
_________________________________________________
Name
_________________________________________________
VS.
_________________________________________________
Address
_________________________________________________
City, State, Zip
DEFENDANT
(Full Name)
1. Cash (on hand or held by others for me)
_________________________________________________
Phone
$ ______________________________________
2. CREDIT UNION ACCOUNTS:
Name
Title (H,W,J)
Credit Balance
Debt Balance
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
3. BANK AND SAVINGS ACCOUNTS:
Company & Branch
(Include Trustee Accounts)
Type of Account
Title (H,W,J)
Current Balance
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
4. SECURITIES:
Company
(Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.)
Title (H,W,J)
Date of Acquisition
Cost
Market Value
Debt Owed Against
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063
American LegalNet, Inc.
www.FormsWorkflow.com
Page 2
5. VEHICLES:
(Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.)
Year
Make
Title (H,W,J)
Currrent Market Value
Debt Owed Against
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
6. REAL PROPERTY:
Address
Fee or Lease
Tltle (H,W,J)
Date of
Acquisition
Cost
Current
Gross Value
Total
Debt Owed
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
7. LIFE INSURANCE:
Company
Person Insured
Face Amount
Beneficiary
Title
(H,W,J)
Cash Value
Debt Owed
Against
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS:
Employer or Company
Title (H,W,J)
Type of Plan
Years in Plan
Total
Value
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
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
Title (H,W,J)
Estimated Gross Value
Debt Owed Against
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063
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 in 2, 4, 5, 6, 7, 9, and 10 above, in
addition to all credit cards, charges, finance companies, and personal loans.)
Debtor
(H,W,J or Other)
Creditor
Security
Mo./Yr.
Debt Incurred
Total
Balance Owed
Minimum Monthly
Payment
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Total Debt in Wife’s Name Alone: ______________________________________________________________________________
Total Debt in Husband’s 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
u
PLAINTIFF’S u DEFENDANT’S SIGNATURE
DATE
u
PLAINTIFF’S u DEFENDANT’S SIGNATURE
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063
American LegalNet, Inc.
www.FormsWorkflow.com