Form 10 STATE OF NORTH CAROLINA COUNTY OF BUNCOMBE IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO._____________ _________________________ DOM:_____________ DOS:____________ Plaintiff, Plaintiff’s Defendant’s vs. EQUITABLE DISTRIBUTION INVENTORY AFFIDAVIT _________________________ Defendant. The undersigned, after being first duly sworn, deposes and says: I hereby certify that the attached Equitable Distribution Inventory Affidavit is a full disclosure of all items of marital, separate and mixed assets, owned on the date of separation, to the best of my knowledge, information and belief. I further certify that the items listed as marital, separate, or mixed property, are categorized based upon the manner in which those items were acquired, possessed, disposed of, titled, gifted, or otherwise obtained under the North Carolina Equitable Distribution Act N.C.G.S § 50-20, et seq. The information contained in the attached Affidavit is true and accurate to the best of my knowledge, information and belief, and as to those matters set forth herein, on information and belief, I believe them to be true. This is the ________day of _____________________, 20___. __________________________________ Plaintiff/ Defendant Sworn to and subscribed before me this the _______ day of ___________________, 20___. Notary Public: _________________________ My commission expires: __________________ American LegalNet, Inc. www.FormsWorkflow.com PART I – MARITAL ____ . ________________ PLAINTIFF ITEM NO. FMV DOS Debt/lien DOS DEFENDANT (H) OR (W) ASSET (H) OR (W) FMV DOS Debt/lien DOS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. American LegalNet, Inc. www.FormsWorkflow.com PART II – SEPARATE Item No. ASSET _____ .___________ PREDOM GIFT INHT. PRESENT FMV FOR COURT USE ONLY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. American LegalNet, Inc. www.FormsWorkflow.com PART III – MIXED Item No. ASSET _____ .________________ EQUITY DOM (H) / (W) FMV DOM FMV DOS Pre-DOS Separate Contribution Pl Def Post-DOS Separate Contribution Pl Def 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. American LegalNet, Inc. www.FormsWorkflow.com PART IV – PENSION Item No. NAME OF PENSION/ RETIREMENT PLAN TOTAL NO. OF MONTHS IN PLAN AS OF DOS TOTAL MONTHS OF MARRIAGE AMT. PAID OR TO BE PAID VALUE AS OF DOS 1. 2. 3. 4. 5. 6. 7. 8. American LegalNet, Inc. www.FormsWorkflow.com PART V – MARITAL DEBT *Current amount owed may be offered into evidence at trial Item No NAME AND ADDRESS OF CREDITOR AMOUNT OWED AT DOS * ITEM PURCHASED OR REASON FOR DEBT DEBT SECU RED? Y?N IF SO, DESCRIBE THE PROPERTY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. American LegalNet, Inc. www.FormsWorkflow.com