NHJB-4004-Se (07/01/2018) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) TRUSTEE DISCLOSURE (RSA 512:9-d) I. On what date were the trustee writ including (attachment and summons or complaint) and trustee disclosure form served upon you? II. What money, rights, goods, chattels, and/or credits belonging to or due defendant did you hold at the time of service? III. Are any of the money, rights, goods, chattels, and/or credits disclosed by you in response to interrogatory II subject to reductions for account fees and/or amounts alleged or determined not to belong to the defendant? If so, please state the amount and the basis. IV. At this time, are you aware whether the money, rights, goods, chattels, and/or credits disclosed by you in response to interrogatory II are subject to priority claims of other people? If so, please state the amount, the basis for the priority claims and the claimants. American LegalNet, Inc. www.FormsWorkFlow.com NHJB-4004-Se (07/01/2018) Page 2 of 2 For non e-filed cases: I state that on this date I am mailing by U.S. mail, or Email (only when there is a prior agreement of the parties to use this method), or hand delivering a copy of this document to: or Other party Other party222s attorney OR For e-filed cases: I state that on this date I am sending a copy of this document as required by the rules of the court. I am electronically sending this document through the court222s electronic filing system to all attorneys and to all other parties who have entered electronic service contacts (email addresses) in this case. I am mailing or hand-delivering copies to all other interested parties. Trustee Signature Print Name of Trustee Trustee Street Address or P.O. Box Trustee Title and Name of Corporation (if applicable) City State Zip code State of , County of This instrument was acknowledged before me on by Date Person Signing Above My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title American LegalNet, Inc. www.FormsWorkFlow.com