IN THE CIRCUIT COURT FOR THE 17th JUDICIAL CIRCUIT WINNEBAGO COUNTY, ILLINOIS IN RE THE MARRIAGE OF ] ] ] ] ] ] Plaintiff and Defendant. Case No. STATEMENT OF ASSETS AND LIABILITIES INSTRUCTIONS (1) All questions require a written response. If you do not have the information requested or do not know the answer to a particular question, indicate that as your answer. (2) Use additional sheets if necessary. Plaintiff/Defendant being duly sworn, states that the following is an accurate statement as of ,2 of his/her assets and liabilities of whatsoever kind and nature and wherever situated), and a statement of assets transferred of whatsoever kind and nature and wherever situated: STATEMENT OF ALL ASSETS - The date of valuation is Description of Asset Title in Name of unless otherwise specified. Date Acquired Pre-marital (PM), Fair Market Inheritance (I) or Value Gift (G) Cash or Cash Equivalents: 1. Savings or interest bearing accounts 2. Checking Accounts 3. Certificates of Deposit A-24 APPENDIX V Page 1 7/99 2002 © American LegalNet, Inc. Description of Asset 4. Pre-marital (PM), Inheritance (I) or Gift (G) Fair Market Value Cash 6. Date Acquired Money Market Accounts 5. Title in Name of Other (specify) Investment Accounts and Securities: 1. Stocks 2. Bonds 3. Tax Exempt Securities 4. Secured or Unsecured Notes 5. Other (specify) A-24-1 APPENDIX V Page 2 7/99 2002 © American LegalNet, Inc. Description of Asset Title in Name of Date Acquired Pre-marital (PM), Inheritance (I) or Gift (G) Fair Market Value Safe Deposit Box (Provide name of bank; description of contents) Real Property: (Provide address, type and description, current fair market value, amounts of mortgages, loans or liens) 1. Residence 2. Secondary or vacation residence 3. Investment or Business Real Estate 4. Vacant Land 5. Other (specify) Motor Vehicle(s), Boats, Trailers, etc.: (Provide year, model, maker, lien, debtor, amount) A-24-2 APPENDIX V Page 3 7/99 2002 © American LegalNet, Inc. Description of Asset Title in Name of Date Acquired Pre-marital (PM), Inheritance (I) or Gift (G) Fair Market Value Business Interests: Type of entity, i.e. Corporations, Partnerships, Sole Proprietorships (Provide percentage interest and number of shares name of business, type of business) Type of Insurance Policies: insurance, i.e. Life, Medical, Disability, Business Overhead, Property, etc. (Provide name of insurer, policy number, name of insured, owner of policy, face amount, beneficiary, cash value, surrender value) Retirement, Pension Plans, IRA Accounts, Deferred Compensation, Annuities, 401(k), Profit Sharing, etc.: (Provide name and type of plan, trustee of plan, beneficiary, vested or nonvested, most current value) Stock Options, ESOPs, Other Deferred Compensation or Employment Benefits: (Describe fully) A-24-3 APPENDIX V Page 4 7/99 2002 © American LegalNet, Inc. Description of Asset Title in Name of Date Acquired Pre-marital (PM), Inheritance (I) or Gift (G) Fair Market Value Income Tax Refunds: Federal and State (Identify tax year) Pending Claims for Personal Injury, Worker’s Compensation or Other Lawsuits Seeking Monetary Award: (Provide date of occurrence, nature and amount of claim, date lawsuit filed, case number, name of plaintiffs, name and address of attorney representing you) Collectibles: Coins, stamps, art, antiques, etc. All Other Property: Personal or Real, NOT PREVIOUSLY LISTED, valued in excess of $500.00 (excluding normal hou s eh o l d f u r n i t u r e a nd furnishings) A-24-4 APPENDIX V Page 5 7/99 2002 © American LegalNet, Inc. STATEMENT OF ASSETS TRANSFERRED (List all assets transferred in any manner during the preceding six (6) months) Description of Property To Whom Transferred and Relationship to Transferee Date of Transfer Value STATEMENT OF OTHER DEBTS/LIABILITIES CREDITOR A-24-5 DEBTOR PURPOSE APPENDIX V Page 6 MARITAL/ NONMARITAL BALANCE DUE 7/99 2002 © American LegalNet, Inc. CONTINGENT DEBTS/LIABILITIES (Provide name of potential obligor/creditor; claimant; basis of claim; date incurred; amount claimed; who incurred.)     Signature of Party: Plaintiff Defendant Type or Print Name VERIFICATION BY CERTIFICATION I certify that all of the corroborating documents to this Statement of Assets and Liabilities in my possession, or that I can obtain upon reasonable effort as of this date, have been provided to the opposing party. UNDER PENALTIES of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, I certify that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters I certify as aforesaid that I verily believes the same to be true. (Signature of Party) (Date) PREPARED BY: A-24-6 APPENDIX V Page 7 7/99 2002 © American LegalNet, Inc.