STATE OF MAINE SUPERIOR COURT , ss Docket No. Plaintiff v. PLAINTIFF'S DEFENDANT'S FINANCIAL STATEMENT [M.R.Civ.P. 108(c)] Defendant INSTRUCTIONS This Financial Statement consists of three parts: Part I, General Statement; Part II, Inventory of Assets and Debts; and Part III, Expenses. You must complete Parts I and II. Complete Part III only if alimony or attorney fees are involved. In each section, number the items you list. If you need additional space, attach the information, and identify all attachments by completing the information requested below. If there is a minor child/are minor children involved, check here and complete a Child Support Affidavit, form FM-050. The original of this Financial Statement signed by the party must be filed with the Court and a copy provided to the other party within 21 days of the Family Division Scheduling Order or before mediation, whichever is earlier. See M.R.Civ. P. 108(c). If a party fails to file a Financial Statement as required by the rules, the Court may make such orders in regard to such failure as are just, including but not limited to imposing sanctions as set forth in M.R.Civ. P. 37(b)(2). FINANCIAL STATEMENT I make this Financial Statement based on my personal knowledge, information and belief. It consists of the following: Parts I and II. (Check this box if neither alimony nor attorney fees are involved.) III. (Check this box if alimony and/or attorney fees are involved.) This Financial Statement includes attachments for each of the following sections of Part II: A B C D E F G H I and attachments for each of the following sections of Part III: A B1 B2 B3 B4 B5 B6 B7 B8 I have furnished the opposing party a copy of this Financial Statement and the following: a. A copy of each of the federal income tax returns I have filed for the last two tax years (if I do not have copies to furnish the opposing party, I shall take steps to get them and will furnish them as soon as I receive them), and b. A copy of each of the last three pay stubs I have received this year. This Financial Statement is complete and is based on my personal knowledge, information, and belief, and to the extent it is based on information, I believe such information to be true. Dated: State of Signature County of DISTRICT COURT LOCATION: Docket No. Personally appeared the above named plaintiff defendant and made oath to the foregoing. Dated: Notary Public Attorney PART I. GENERAL STATEMENT In this case, the following categories of property and property interests are involved. (Check all items that apply.) A. Real Estate E. Stocks, bonds, and other securities B. Vehicles F. Life and disability insurance C. Tangible personal property (Household furniture G. Business interests and furnishings, jewelry, art objects, antiques, tools, H. Other assets (Any assets not listed in any other recreation equipment, etc.) category.) D. Cash, bank accounts, pensions, and retirement accounts I. Debts (Personal and business debts, credit card payments, unpaid medical expenses, and other debts whether or not secured by lien or mortgage.) Pursuant to M.R.Civ.P. 108(d)(3), the information on this form is not subject to public inspection. FM-043, Rev. 10/10 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com PART II. ASSETS AND DEBTS I and/or my spouse own the following property and property interests and owe the following debts. List all the property and property interests owned, and the debts owed by you and/or your spouse. If you claim any asset or debt item to be nonmarital, check it in the Nonmarital column and attach a full statement of the facts you rely on to support your claim. A. REAL ESTATE. List any interest in real estate (land, land and buildings) owned by you or your spouse. If there is a debt secured by the real estate (a mortgage), check in the debt column and list the debt/mortgage in Section I, Debts, on page 4. If you need more space, check here and add attachments as necessary. *You must include the Registry of Deeds information (book and page) for the deed to any real estate. You can obtain this information at the Registry of Deeds in the county where the property is located. Address of Property 1. Percent of Ownership County Recorded Book and Page* Date Purchased Current Value Debt owed on real estate Nonmarital B. VEHICLES. List all vehicles (cars, trucks, snowmobiles, ATVs, boats, airplanes, etc.) owned by your or your spouse. Give your best estimate of the current market value, not replacement cost, of each vehicle. Do not deduct debts secured by a vehicle. If there is a debt, check in the debt column and list the debt in Section I, Debts, on page 4. If you need more space, check here here and add attachments as necessary. Year, make, model and description of each vehicle 1. Date Acquired Current Value Debt Nonmarital C. TANGIBLE PERSONAL PROPERTY. List all items of tangible personal property having a value in excess of $100 each, giving your best estimate of the current market value, not the replacement cost. Examples are household furniture and furnishings, jewelry, art objects, antiques, tools, recreation equipment, etc. Do not deduct debts secured by any item. If there is a debt, check in the debt column and list the debt in Section I, Debts, on page 4. If you need more space, check here and add attachments as necessary. Description of each item with a value in excess of $100 1. Date Acquired Current Value Debt Nonmarital Pursuant to M.R.Civ.P. 108(d)(3), the information on this form is not subject to public inspection. FM-043, Rev. 10/10 Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com D. CASH, BANK ACCOUNTS, PENSIONS, AND RETIREMENT ACCOUNTS. List cash, all savings and checking accounts, money market accounts, certificates of deposit, profit sharing plans, pension plans, IRAs, Keoughs, annuities, etc. Give current market value of each item. If you need more space, check here and add attachments as necessary. Name of Institution 1. Description of Account Date Acquired Account Number Current Value Nonmarital E. STOCKS, BONDS, AND OTHER SECURITIES. List all stocks, bonds, warrants, options, debentures, notes, or any other securities. Give your best estimate of the current market value of each item. Do not deduct debts secured by any item. If there is a debt, check in the debt column and list the debt in Section I, Debts, on page 4. If you need more space, check here and add attachments as necessary. Name 1. Description and Number of Units