Form 11 See Instructions STATE OF NORTH CAROL INA IN THE GENERAL COURT OF JUS TICE DISTR ICT COURT DIVIS ION COUNTY OF BUNCOMBE FILE NO._____________ ____________________________ DOM:__________ DOS:___________ Plaintiff, Plaintiffs Defendants vs. FINAL EQUITA BLE DISTR IBUTION AF FIDAVIT ____________________________ Defendant. The undersigned, after being first duly sworn, deposes and says: I hereby certify that the attached Final Equitable Distribution 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 true. I further certify that those items listed as marital, separate, or mixed property, are property categorized based upon the manner in which those items were acquired, possessed, disposed of, titled, gifted, or otherwise, under the North Carolina Equitable Distribution Act N.C.G.S 50- 20, et seq. I further certify that the valuations listed on the affidavit represent the appropriate fair market value of each asset to the best of my knowledge, information, and belief. I further certify that the attached affidavit is a full disclosure of all items of marital, separate, and mixed assets, owned on the date of separation. 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.USCourtForms.com>>>> 2 PART 1 MARITAL ___ . ________________ PLAINTIFF DEFENDANT ITEM FMV Debt/lien (H) (H) FMV Debt/lien OR ASSET OR NO. DOS DOS DOS DOS (W) (W) 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.USCourtForms.com>>>> 3 PART II SEPARATE _____. ____________ Item PRE- PRESENT ASSET GIFT INHT. FOR COURT USE ONLY No. DOM FMV 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. American LegalNet, Inc. www.USCourtForms.com>>>> 4 PART III MIXED ______. _________________ Pre-DOS Post-DOS EQUITY Item FMV FMV Separate Separate ASSET DOM No. DOM DOS Contribution Contribution (H) / (W) Pl Def Pl Def 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. American LegalNet, Inc. www.USCourtForms.com>>>> 5 PART IV PENSION TOTAL NO. Item NAME OF PENSION/ RETIREMENT OF MONTHS TOTAL AMT. PAID OR TO VALUE AS OF MONTHS OF No. PLAN IN PLAN AS MARRIAGE BE PAID DOS OF DOS 1. 2. 3. 4. 5. 6. 7. 8. American LegalNet, Inc. www.USCourtForms.com>>>> 6 PART V MARITAL DEBT *Current amount owed may be offered into evidence at trial AMOUNT ITEM DEBT Item OWED PURCHASED SECU IF SO, DESCRIBE NAME AND ADDRESS OF CREDITOR No AT DOS OR REASON RED? THE PROPERTY * FOR DEBT Y/N 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. American LegalNet, Inc. www.USCourtForms.com