Rule 30E (10/31/95) PART 1 – MARITAL ________________________ ________________________ The “(H) or (W)” column is for the purpose of indicating preference in distribution between Husband and Wife 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. 1 American LegalNet, Inc. www.FormsWorkflow.com Rule 30E (10/31/95) PART 2 – SEPARATE _______________________ Item No. PREDOM ASSET 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. 18. 2 American LegalNet, Inc. www.FormsWorkflow.com Rule 30E (10/31/95) PART 3 – MIXED ________________________ Item No. EQUITY DOM (H) / (W) ASSET FMV DOM FMV DOS ________________________ PLAINTIFF CONTRIBUTION POST DOM DEFENDANT CONTRIBUTION POST DOM 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 3 American LegalNet, Inc. www.FormsWorkflow.com Rule 30E (10/31/95) PART 4 – PENSION 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 4 American LegalNet, Inc. www.FormsWorkflow.com Rule 30E (10/31/95) PART 5 – MARITAL DEBT *Current amount owed may be offered into evidence at trial NAME AND ADDRESS OF CREDITOR AMOUNT OWED AT DOS * ITEM PURCHASED OR REASON FOR DEBT DEBT SECURED? IF SO, DESCRIBE THE PROPERTY FOR COURT USE ONLY 5 American LegalNet, Inc. www.FormsWorkflow.com Rule 30E (10/31/95) PART 6– INCOME AND EXPENSESSEPARATE GROSS INCOME STATEME NT Weekly Monthly Bi-Weekly Salary & Wages (Include bonuses, commissions, overtime and tips) Pensions and retirement Social Security Disability and Unemployment benefits Public Assistance (AFDC, food stamps, etc.) Rents Child support/ alimony payments Dividends and Interest income from all other sources (list each) TOTAL GROSS INCOME DEDUCTIONS FROM GROSS INCOME Federal income taxes State income taxes Union or other dues Retirement or pension fund Social Security Savings Medical insurance Other deductions TOTAL DEDUCTIONS AVERAGE MONTHLY EXPENSES Rent or mortgage Utilities & telephone Taxes and insurance Clothing & laundry Maintenance Food and household supplies Medical & Dental Child care Other TOTAL EXPENSE 6 American LegalNet, Inc. www.FormsWorkflow.com