NORTH CAROLINA IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION CABARRUS COUNTY FILE NUMBER 01 CVD ____________________________ ) Plaintiff, ) EQUITABLE DISTRIBUTION vs. ) INVENTORY AFFIDAVIT _____________________________ ) Defendant. ) NOW COMES the plaintiff in the above-entitled equitable distribution action, and, in accordance with the provisions of G.S. 50-22(a) and the 19A Local Rules, itemizes for the Court and the opposing party what he or she alleges to be the marital and separate property of the parties hereto, as well as the marital debts of the parties hereto, all as set out on the following schedules which are attached hereto and incorporated herein by reference as if fully set out at this point. Plaintiff certifies that he/she has made a full and complete disclosure of all marital and separate property known to him/her. Plaintiff has filed the original of this Affidavit with the Clerk, and has served a filed copy of this affidavit on the defendant, or attorney for defendant, as witnessed by the Certificate of Service attached hereto. Pursuant to the 19A Local Rules, the defendant is required to complete his or her portion of the Affidavit as indicated thereon within thirty days from its receipt. Defendant must then file the same promptly thereafter with the Clerk, and forward a completed copy of the Affidavit to the plaintiff. This the _________ day of ____________________, 2001. ___________________________________ >>>> 2SCHEDULE I REAL PROPERTY AND MOBILE HOME PLAINTIFFS CONTENTIONS DEFENDANTS CONTENTIONS PROPERTY DOS DOS WHO X IF X IF X IF DOS DOS COMMENTS FMV MTG. HAS YOU YOU YOU FMV MTG. POSS. WANT WANT AGREE 1. 2. 3. 4. 5. 6. SCHEDULE II MOTOR VEHICLES PLAIN TIFFS CONTENTIONS DEFENDANTS CONTENTIONS PROPERTY DOS DOS WHO X IF X IF X IF DOS DOS COMMENTS FMV MTG. HAS YOU YOU YOU FMV MTG. POSS. WANT WANT AGREE 1. 2. 3. >>>> 3 SCHEDULE III HOUSEHOLD FURNISHINGS REAL PROPERTY AND M OBILE HOME PLAINTIFFS CONTENTIONS DEFENDANTS CONTENTIONS ITEM DOS WHO X IF X IF X IF YOU DOS WHO COMMENTS NET HAS YOU YOU AGREE NET HAS VALUE POSS. WANT WANT VALUE POSS. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. >>>> 4 SCHEDULE IV MISCELLANEOUS PERSONAL PROPERTY (Tools, Guns, Lawn Equipment, Jewelry) PLAINTIFFS CONTENTIONS DEFENDANTS CONTENTIONS PROPERTY DOS DOS WHO X IF X IF X IF DOS DOS COMMENTS FMV MTG. HAS YOU YOU YOU FMV MTG. POSS. WANT WANT AGREE 1. 2. 3. 4. 5 6. 7. SCHEDULE V ACCOUNTS (Checking, Savings, CDs, Stocks) PLAINTIFFS CONTENTIONS DEFENDANTS CONTENTIONS FINANCIAL INSTITUTION _____________________________________________________ ______________________________________________________________________________ DOS VALUE _________________________ X IF YOU WANT _____________________ X IF YOU WANT X IF YOU AGREE ____________________ X IF YOU AGREE WHO HAS POSS _____________________ DOS VALUE COMMENTS _____________________________________________________________________________________________ >>>> 5 SCHEDULE VI RETIREMENT (Pension, 401(k), Profit-sharing, IRA) NAME -INSTITUTION _________________________________________________________ _____________________________________________________________________________ DOS VALUE MARITAL VALUE PL/DEF. __________________ _________________ _________________ SCHEDULE VII DEBTS CREDITOR __________________________________________________________________ ____________________________________________________________________________ DOS VALUE $ ___________________________________ AMOUNT OWED $ ________________________________________________ PARTY PAID ____________________________________________________ SINCE SEPARATION _____________________________________________- AMOUNT PAID___________________________________________________________ >>>> 6NORTH CAROLINA ) ) VERIFICATION OF PLAINTIFF CABARRUS COUNTY ) _____________________________________________, being first duly sworn, deposes and says: That he/she is the plaintiff in the foregoing equitable distribution action; that he/she has prepared the foregoing Equitable Distribution Inventory Affidavit and knows the contents thereof; that the same is true to his or her own knowledge, except as to those matters and things therein set out on information and belief, and as to those matters and things, he/she believes it to be true. SWORN TO and subscribed before me this the ______ day of ________, 2001. _______________________________ Notary Public My Commission Expires: __________ CERTIFICATE OF SERVICE I hereby certify that I served a copy of the foregoing EQUITABLE DISTRIBUTION INVENTORY AFFIDAVIT upon ________________________, ______________________, ____________________, North Carolina, by depositing a copy thereof in the United States mail in an envelope with sufficient postage thereon addressed to him/her at the aforesaid address. This the _____ day of _________________ , ______ . ________________________________