IN THE CIRCUIT COURT OF JACKSON COUNT Y, MISSOURI FAMILY COURT DIVISION AT KANSAS CITY AT INDEPENDENCE IN RE THE MARRIAGE OF: ) ) ) Petitioner, ) and ) Case No.: ________________________ ) ) Division: _________________________ Respondent. ) MODIFICATION STATEMENT OF ASSETS AND DEBTS OF Present Fair Amount Equity Market Value owed A. REAL ESTATE : List value of all real estate B. MOTOR VEHICLES: List value of all autos, boats, trailers, aircraft, recreational vehicles and campers and vehicle leases. C. BANK ACCOUNTS: List total amount in all checking, savings and money market accounts, certificates of deposit, held in your name alone or with another person. D. SECURITIES: List total value of all stocks, bonds, promissory notes, mortgages, etc. E. LIFE INSURANCE: List total cash value. F. RETIREMENT, PENSION, PROFIT SHARING : List name of the company and the present vested value of all plans. G. DEBTS OWED TO YOU BY OTHERS: List total debt amount. H. INTEREST IN SOLE PROPRIETORSHIP , PARTNERSHIPS, OR JOINT VENTURES: List total value. I. INTEREST IN PENDING LITIGATION OR SUIT NOT YET FILED: List total value. J. CASH ON HAND: K. HOUSEHOLD GOODS & PERSONAL GOODS: List the total value of all. L. OTHER ASSETS: List the total value of all assets not already listed herein, i.e., trusts. Form 1402E Adopted 1/17/03 Effective 2/19/03 >>>> 2 DEBTS : A. List all loans from any bank, credit union, savings and loan association or other lending institution. Indicate who signed the loan, the date of the loan, purpose of the loan, actual disposition of the proceeds and state the name and address of the lender. Also, list all credit card balances and store charges. State whose name is on the credit card . Also list all other indebtedness and give the name and address of the creditor. DESCRIPTION: CURRENT SECURED REQUIRED BALANCE YES/NO MONTHLY PAYMENT AFFIDAVIT I certify that I have read the above Statement of Assets and Debts and the facts therein are complete, true and accurate to the best of my knowledge and belief. A FFIANT, Subscribed and sworn to before me, the undersigned Notary Public on _________________________. My Commission Expires: N OTARY PUBLIC Form 1402E Adopted 1/17/03 Effective 2/19/03