Statement of Property and Debt (For use in Modification Cases) Page 1 of 3 Form CAFC140 01/01/2019 This form is available for free at www.selfrepresent.mo.gov IN THE CIRCUIT COURT OF , MISSOURI (County where court is located. City of Saint Louis is considered a county.) Case (First Name) (Middle Name) (Last Name) (Jr./Sr./III)NumberPetitioner, (Enter full legal name of the person who filed the original petition)(Use number on Motion) original petition) v. Division (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Respondent. (Enter full legal name of the person who responded to the(First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Enter your full legal name above) Number Statement of Property and Debt (For use in Modification Cases) Statement completed by Your Property (either alone or with anyone else) (Check 223Yes224 or 223No224 for each of the following questions) Estimated Value Do you own a house, condominium or other real estate? Yes No Do you own a car, truck or motorcycle? Yes No Do you own a mobile home, trailer, boat or airplane? Yes No Do you have any bank accounts? Yes No Do you have any right to receive any pension or retirement benefits other than Social Security? Yes No Do you have an IRA or 401(k) or other retirement account? Yes No Do you have any furniture, appliances or other household goods worth more than $100? Yes No Do you have any jewelry, clothing or other personal items worth more than $100? Yes No Do you own a business? Yes No Do you own any stocks or bond? Yes No Do you have any life insurance that could be cashed in? Yes No Does anyone owe you money? Yes No Do you have any lawsuits against anyone? Yes No Do you have any farm equipment, animals or crops? Yes No Do you have any interest in any trusts? Yes No Do you have any other asset or property? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Statement of Property and Debt (For use in Modification Cases) Page 2 of 3 Form CAFC140 01/01/2019 This form is available for free at www.selfrepresent.mo.gov Your Debts (either alone or with anyone else) (Check 223Yes224 or 223No224 for each of the following questions) Amount Due Are you currently in a bankruptcy proceeding? (Chapter 7 or Chapter 13) Yes No Do you owe a mortgage on a house or condominium or land? Yes No Do you owe money on a car? Yes No Do you owe money on any credit cards? Yes No Do you owe any money to any family or friends? Yes No Do you owe any medical or dental bills? Yes No Do you owe any student loans? Yes No Do you owe any other debts? Yes No What debts should I list on this form? All debts owed by you should be listed. You should list all loans from any individual, bank, credit card company, credit union, savings and loan association or other lending institution. Make sure to list all credit cards and any amounts owed pursuant to any bankruptcy or other repayment plans. Proof of Service on Other Parties You must send (serve) a copy of this document to each of the other parties, or their attorney(s). To obtain service, you may deliver the document by hand; send it by First Class U.S. mail, e-mail or facsimile (fax); or leave it at the office of the party222s attorney to be served with a clerk, receptionist or an attorney associated with the attorney to be served. I certify, under oath that on (date) I have sent/given a copy of this Statement of Property and Debt (For use in Modification Cases) to each of the following parties at the address shown: Name Address: U.S. mail/e-mail/fax number American LegalNet, Inc. www.FormsWorkFlow.com Statement of Property and Debt (For use in Modification Cases) Page 3 of 3 Form CAFC140 01/01/2019 This form is available for free at www.selfrepresent.mo.gov Sign Below in the Presence of a Notary Public Your Statement of Property and Debt (For use in Modification Cases) is required to be verified in the presence of a notary public. , of lawful age, being duly sworn on his or her oath, states that he or she is the person named above and that the facts stated in this Statement of Property and Debt (For use in Modification Cases) are true according to his or her best knowledge, information and belief. (Sign above in the presence of a Notary Public) (Print your name above) The following information must be completed by a notary public. STATE OF ) ) SS COUNTY OF ) On this day of , 20 , before me personally appeared, , to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County and State aforesaid, the day and year first above written. , Notary Public County, State of Missouri My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com