IN THE ________ JUDICIAL CIRCUIT COURT, __________________________, MISSOURI Judge or Division: Case Number: In RE the Marriage of : Petitioner: SSN (last four digits): vs. Respondent: SSN (last four digits): (Date File Stamp) Statement of Marital and Non-Marital Assets and Debts Name of submitting party _________________________________________________________________________ Address of submitting party _______________________________________________________________________ If there is not sufficient room on this form, supplement each answer by attaching additional sheets as needed. Show only dollar amounts rounding to the nearest dollar. I. MARITAL PROPERTY* * Marital Property means all property acquired by either spouse subsequent to the marriage except; 1. Property acquired by gift, bequest, devise, or descent; 2. Property acquired in exchange for property acquired prior to the marriage or in exchange for property acquired by gift, bequest, devise, or descent; 3. Property acquired by a spouse after a decree of legal separation; 4. Property excluded by valid written agreement of the parties; and 5. The increase in value of property acquired prior to the marriage or pursuant to subdivisions (1) to (4) above, unless marital assets, including labor, have contributed to such increases and then only to the extent of such contributions. A. REAL ESTATE – List interest in real estate including leaseholds. Include address, legal description, names of mortgagor(s) or lessor(s). OSCA (04-02) CV105 Present Fair Market Value 1 of 7 Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com B. MOTOR VEHICLES – Include all automobiles, boats, trailers, aircraft, recreational vehicles and campers. List year, make, model, vehicle identification number and names of mortgagors. Present Fair Market Value Amount Owed C. BANK ACCOUNTS – List all checking and savings accounts, time deposit, money markets, certificates, etc. held in your name alone or in your name and another person. Give the names of the institutions, the names on the accounts and the last four digits of the account numbers. Present Fair Market Value Amount Owed D. CASH ON HAND Present Fair Market Value Amount Owed E. SECURITIES – List all stocks, both public and closely held corporations, bonds, promissory notes, mortgages, money market funds and all other property in which you have an interest. Give names in which securities are held and identification numbers. Present Fair Market Value OSCA (04-02) CV105 2 of 7 Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com F. LIFE INSURANCE – List the type of policy, name of issuing company, policy number, owner of policy, insured, beneficiaries, face value and cash value (include policies furnished by your employer). Present Fair Market Value Amount Owed G. HOUSEHOLD GOODS & PERSONAL GOODS – Below or on a separate sheet, list all household goods, and personal goods, including all appliances, furniture, silver, antiques, art collectibles, televisions, stereos, clothing, jewelry, furs, cameras, coin and stamp collections, tools, firearms, sporting equipment, lawn and garden equipment, etc. Present Fair Market Value Amount Owed OSCA (04-02) CV105 3 of 7 Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com HOUSEHOLD GOODS & PERSONAL GOODS - continued Present Fair Market Value Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife H. RETIREMENT, PENSION AND/OR PROFIT SHARING – List the name of the company, the person holding the interest, the percentage vested, and the present total value. Present Fair Market Value Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife I. INTEREST IN TRUST – List any interest in a trust. Give name of the trust, name of the trustee, settlor, beneficiaries, nature of the interest you have in the trust and attach to this statement a copy of the trust instrument. Present Fair Market Value Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife J. INTEREST IN CONTRACTS MADE AND NOT PERFORMED – List the parties to the contract, your interest in the contract and the expected date of performance, if any. OSCA (04-02) CV105 Present Fair Market Value 4 of 7 Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com K. INTEREST IN PENDING LITIGATION OR SUIT NOT YET FILED. Present Fair Market Value L. INTEREST IN FARM EQUIPMENT, CROPS, ANIMALS – List the nature of the property and location. Present Fair Market Value M. DEBTS OWED TO YOU BY OTHERS – List the name of the debtor, any security, date of loan and due date, if any. Present Fair Market Value N. INTERESTS IN SOLE PROPRIETORSHIPS, PARTNERSHIPS, OR JOINT VENTURES – List the percent interest you hold. Present Fair Market Value O. OTHER ASSESTS – List all assets not already listed herein. (Note who has possession of these items.) Present Fair Market Value OSCA (04-02) CV105 5 of 7 Amount Owed Amount Owed Amount Owed Amount Owed Amount Owed Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife Equity Recommended Award to Husband or Wife Who Presently Possesses Husband or Wife 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com II. NON-MARITAL PROPERTY: Property owned since before the marriage, and property acquired after the marriage: 1. By gift, bequest, devise, or descent; 2. In exchange for property acquired prior to the marriage or in exchange for property acquired by gift, bequest, devise, or descent; 3. By a spouse after a decree of legal separation; and 4. By valid written agreement of the parties. For each item of non-marital property, indicate how acquired and approximate date of acquisition. Item Present Value Amount Owed Equity Alleged Owner Husband or Wife III. DEBTS: 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, 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. Creditor OSCA (04-02) CV105 Current Balance 6 of 7 Secured Yes/No Required Monthly Payment Indicate Debt Incurred by Husband, Wife, or Joint 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com Summary VALUE I. DEBT EQUITY Marital Property: A. Real Estate B. Motor Vehicles C. Bank Accounts D. Cash on Hand E. Securities F. Life Insurance G. Household Goods & Personal Goods H. Retirement, Pension and/or Profit Sharing I. J. K. L. M. N. O. Interest in Trust Interest in Contracts Made & Not Performed Interest in Pending Litigation or Suit not yet Filed Interest in Farm Equipment, Crops, Animals Debts Owed to You by Others Interest in Sole Proprietorships, Partnerships, or Joint Ventures Other Assets II. Non-Marital Property III. Debts TOTALS Affidavit I certify under penalty of perjury that the above Statement of Marital and Non-Marital Property and Liabilities is complete, true and accurate to the best of my knowledge and belief. ______________________________________________ Affiant Subscribed and sworn to before me, the undersigned Notary Public, on ______________________________ (date) My Commission Expires: ___________________________________________ Date OSCA (04-02) CV105 ______________________________________________ Notary Public 7 of 7 452.330 RSMo American LegalNet, Inc. www.FormsWorkFlow.com