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Property Questionnaire

    REAL PROPERTY

    First Name:

    Last Name:

    Phone:

    Email:

    City:

    State:

    Zip:

    Primary Residence (Homestead)

    Address

    Description of improvements, if any

    Legal description (from deed)

    Date purchased:

    Who is on Title:

    Purchase price

    Current fair market value as of

    (date)

    (value)

    Mortgage company

    Mortgage account number (if any)

    Outstanding mortgage balance as of

    (date)

    (balance)

    Second lien

    Outstanding second lien balance as of

    (date)

    (balance)

    Monthly payments

    Current net equity in property as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSell

    Choose One

    AgreedProposed

    Other Real Property Interest

    Address

    Description of improvements, if any

    Legal description (from deed)

    Date purchased

    Purchase price

    Current fair market value as of

    (date)

    (value)

    Mortgage company

    Mortgage account number (if any)

    Outstanding mortgage balance as of

    (date)

    (balance)

    Second lien

    Outstanding second lien balance as of

    (date)

    (balance)

    Monthly payments

    Current net equity in property as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSell

    Choose One

    AgreedProposed

    MINERAL INTERESTS

    Name of mineral interest/lease/well

    Type of interest

    Legal description (from deed or division order)

    County of location

    Name of producer/operator

    Current Value as of

    (date)

    (balance)

    How Acquired

    When

    By Whom

    Choose One

    Award to HusbandAward to WifeSell

    Choose One

    AgreedProposed

    Name of mineral interest/lease/well

    Type of interest

    Legal description (from deed or division order)

    County of location

    Name of producer/operator

    Current Value as of

    (date)

    (balance)

    How Acquired

    When

    By Whom

    Choose One

    Award to HusbandAward to WifeSell

    Choose One

    AgreedProposed

    CASH AND ACCOUNTS WITH FINANCIAL INSTITUTIONS

    Cash on hand as of

    (date)

    (amount)

    Traveler's checks on hand as of

    (date)

    (amount)

    Money orders on hand as of

    (date)

    (amount)

    Name of financial institution

    Type of account

    Name account held in

    Account number

    Date account was opened

    Persons named on withdrawal cards

    Account balance as of:

    (date)

    (amount)

    Choose One

    Award to HusbandAward to WifeClose

    Choose One

    AgreedProposed

    Name of financial institution

    Type of account

    Name account held in

    Account number

    Date account was opened

    Persons named on withdrawal cards

    Account balance as of:

    (date)

    (amount)

    Choose One

    Award to HusbandAward to WifeClose

    Choose One

    AgreedProposed

    Name of financial institution

    Type of account

    Name account held in

    Account number

    Date account was opened

    Persons named on withdrawal cards

    Account balance as of:

    (date)

    (amount)

    Choose One

    Award to HusbandAward to WifeClose

    Choose One

    AgreedProposed

    Name of financial institution

    Type of account

    Name account held in

    Account number

    Date account was opened

    Persons named on withdrawal cards

    Account balance as of:

    (date)

    (amount)

    Choose One

    Award to HusbandAward to WifeClose

    Choose One

    AgreedProposed

    BROKERAGE/MUTUAL FUND ACCOUNTS (include accounts not previously disclosed herein)

    Name of brokerage firm/mutual fund

    Address of brokerage firm

    Name account held in

    Name of account (and names of subaccounts, if any)

    Account number (and numbers of subaccounts, if any)

    Total account value as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of brokerage firm/mutual fund

    Address of brokerage firm

    Name account held in

    Name of account (and names of subaccounts, if any)

    Account number (and numbers of subaccounts, if any)

    Total account value as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of brokerage firm/mutual fund

    Address of brokerage firm

    Name account held in

    Name of account (and names of subaccounts, if any)

    Account number (and numbers of subaccounts, if any)

    Total account value as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    STOCKS, BONDS, OPTIONS AND OTHER INVESTMENT INSTRUMENTS

    Name of security/investment

    Type of security/investment (common stock/preferred stock/bond, etc.)

    Type of security/investment (common stock/preferred stock/bond, etc.)

    Certificate numbers

    Name in which held

    In possession of

    Date of initial ownership

    Name of exchange on which listed

    Brokerage house

    Brokerage house account number

    Present location of certificate(s)

    Is the security pledged as collateral?

    YesNo

    If so, to whom or to what entity?

    Market value as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of security/investment

    Type of security/investment (common stock/preferred stock/bond, etc.)

    Type of security/investment (common stock/preferred stock/bond, etc.)

    Certificate numbers

    Name in which held

    In possession of

    Date of initial ownership

    Name of exchange on which listed

    Brokerage house

    Brokerage house account number

    Present location of certificate(s)

    Is the security pledged as collateral?

    YesNo

    If so, to whom or to what entity?

    Market value as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    RETIREMENT ACCOUNTS

    Retirement Accounts/SEP/401(k):

    Name of plan

    Financial institution

    Name account held in

    Account number

    Payee of survivor benefits

    Designated beneficiary

    Total account balance:

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of plan

    Financial institution

    Name account held in

    Account number

    Payee of survivor benefits

    Designated beneficiary

    Total account balance:

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of plan

    Financial institution

    Name account held in

    Account number

    Payee of survivor benefits

    Designated beneficiary

    Total account balance:

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Company Retirement Benefits:

    Defined Contribution Plans

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Payee of survivor benefits

    Description of other benefits

    Balance of account as of date of marriage:

    Is there a loan or offset against the plan?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Total account balance as of:

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Payee of survivor benefits

    Description of other benefits

    Balance of account as of date of marriage:

    Is there a loan or offset against the plan?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Total account balance as of:

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Defined Benefit Plans

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Description of other benefits

    Accrued benefit as of date of marriage

    Value of plan as of:

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Description of other benefits

    Accrued benefit as of date of marriage

    Value of plan as of:

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Uniformed Services

    Branch of service

    Name of service member

    Current Rank/Pay grade of service member

    Starting date of creditable service

    Status of service member

    ActiveReserveRetired

    Payee of survivor benefits

    Description of other benefits

    Monthly benefit payable

    Value of plan as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Branch of service

    Name of service member

    Current Rank/Pay grade of service member

    Starting date of creditable service

    Status of service member

    ActiveReserveRetired

    Payee of survivor benefits

    Description of other benefits

    Monthly benefit payable

    Value of plan as of:

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Other Retirement Accounts

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Payee of survivor benefits

    Description of other benefits

    Balance of account as of date of marriage

    Is there a loan or offset against the plan?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Total account balance as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Exact name of plan

    Name, address, and phone number of plan administrator

    Name of employee

    Name of employer

    Starting date of creditable service/Beginning date of participation in plan

    Percentage employee is vested

    Designated beneficiary

    Payee of survivor benefits

    Description of other benefits

    Balance of account as of date of marriage

    Is there a loan or offset against the plan?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Total account balance as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    EMPLOYEE-RELATED BENEFITS

    Stock Options and Restricted Stock

    Stock Options

    Name of company

    Date of option/grant

    Vesting schedule

    Number of options

    Are the options exercisable?

    YesNo

    Are the options registered?

    YesNo

    Current stock price

    Strike price

    Current net market value as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Restricted Stock

    Name of company

    Date of grant

    Restriction schedule

    Number of shares

    Are the stocks registered?

    YesNo

    Current stock price

    Current market value as of

    (date)

    (balance)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Bonuses

    Name of company

    Name or description of bonus

    Date of bonus expected to be paid

    Time period covered by bonus

    Anticipated amount of bonus

    Form of bonus to be paid

    Name of company

    Name or description of bonus

    Date of bonus expected to be paid

    Time period covered by bonus

    Anticipated amount of bonus

    Form of bonus to be paid

    OTHER EMPLOYEE-RELATED BENEFITS

    Name of company

    Name or description of benefit

    Date benefit is expected to be paid

    Time period covered by benefit

    Anticipated amount of benefit

    Form of benefit to be paid

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of company

    Name or description of benefit

    Date benefit is expected to be paid

    Time period covered by benefit

    Anticipated amount of benefit

    Form of benefit to be paid

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    LIFE INSURANCE AND ANNUITIES:

    Insurance Company

    Policy No.

    Type of policy

    Name of insured

    Name of owner

    Beneficiary

    Date of issue

    Face amount or death benefit

    Amount of premiums

    Due dates of premiums

    Is there a loan against this policy?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Cash surrender value as of

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Insurance Company

    Policy No.

    Type of policy

    Name of insured

    Name of owner

    Beneficiary

    Date of issue

    Face amount or death benefit

    Amount of premiums

    Due dates of premiums

    Is there a loan against this policy?

    YesNo

    If so, how much?

    Date any such loan or withdrawal was made

    Cash surrender value as of

    (date)

    (value)

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    CLOSELY HELD BUSINESS INTERESTS/CORPORATIONS/PARTNERSHIPS

    Name of business

    Type

    Date of initial ownership

    Name of owner

    Shares, units or percentage of ownership

    Estimated fair market value

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of business

    Type

    Date of initial ownership

    Name of owner

    Shares, units or percentage of ownership

    Estimated fair market value

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name of business

    Type

    Date of initial ownership

    Name of owner

    Shares, units or percentage of ownership

    Estimated fair market value

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    CONTENTS OF SAFE DEPOSIT BOX/HOME SAFE/STORAGE FACILITY:

    Name and location of facility

    Account/box number/unit number

    Names of persons with access to contents

    Terms and length of lease

    Items in safe-deposit box or storage unit

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Name and location of facility

    Account/box number/unit number

    Names of persons with access to contents

    Terms and length of lease

    Items in safe-deposit box or storage unit

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    MOTOR VEHICLES, BOATS, AIRPLANES, CYCLES, TRAILERS, RVs, ETC.:

    Description (year, make, and model)

    Vehicle identification no.

    Exact name on certificate of title

    In possession of

    Date purchased

    Purchase price

    Does vehicle have a loan against it?

    AgreedProposed

    If yes, state amount of loan

    Exact name of creditor

    Fair Market value

    Net equity

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Description (year, make, and model)

    Vehicle identification no.

    Exact name on certificate of title

    In possession of

    Date purchased

    Purchase price

    Does vehicle have a loan against it?

    AgreedProposed

    If yes, state amount of loan

    Exact name of creditor

    Fair Market value

    Net equity

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Description (year, make, and model)

    Vehicle identification no.

    Exact name on certificate of title

    In possession of

    Date purchased

    Purchase price

    Does vehicle have a loan against it?

    AgreedProposed

    If yes, state amount of loan

    Exact name of creditor

    Fair Market value

    Net equity

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    Description (year, make, and model)

    Vehicle identification no.

    Exact name on certificate of title

    In possession of

    Date purchased

    Purchase price

    Does vehicle have a loan against it?

    AgreedProposed

    If yes, state amount of loan

    Exact name of creditor

    Fair Market value

    Net equity

    Choose One

    Award to HusbandAward to WifeSplit

    Choose One

    AgreedProposed

    MISCELLANEOUS PERSONAL PROPERTY:

    HOUSEHOLD FURNITURE, FURNISHINGS & FIXTURES:

    Description

    Estimated value

    Award To

    Agreed or Proposed

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    CLOTHING, JEWELRY, AND ITEMS OF PERSONAL ADORNMENT:

    Description

    Estimated value

    Award To

    Agreed or Proposed

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    MISCELLANEOUS SPORTING GOODS AND FIREARMS:

    Description

    Estimated value

    Award To

    Agreed or Proposed

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      ELECTRONICS AND COMPUTERS, OFFICE EQUIPMENT AND FURNITURE:

      Description

      Estimated value

      Award To

      Agreed or Proposed

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      ANTIQUES, ARTWORKS AND COLLECTIONS:

      Description

      Estimated value

      Award To

      Agreed or Proposed

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      CLUB MEMBERSHIPS:

      Name of club

      Name membership held in

      Type

      Debt

      Current Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name of club

      Name membership held in

      Type

      Debt

      Current Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name of club

      Name membership held in

      Type

      Debt

      Current Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      TRAVEL AWARDS/FREQUENT FLYER MILEAGE ACCOUNTS, ETC.:

      Exact name of airline/program

      Account number

      Current number of miles/points

      Name of owner

      Value of account

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Exact name of airline/program

      Account number

      Current number of miles/points

      Name of owner

      Value of account

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Exact name of airline/program

      Account number

      Current number of miles/points

      Name of owner

      Value of account

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Exact name of airline/program

      Account number

      Current number of miles/points

      Name of owner

      Value of account

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Exact name of airline/program

      Account number

      Current number of miles/points

      Name of owner

      Value of account

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      SPORTS AND CULTURAL TICKETS AND MEMBERSHIPS

      Type

      Cost

      Number of seats

      Debt

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Type

      Cost

      Number of seats

      Debt

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      LIVESTOCK/PETS:

      Description

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Visitation Schedule YN

      Choose One

      AgreedProposed

      Description

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Visitation Schedule YN

      Choose One

      AgreedProposed

      Description

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Visitation Schedule YN

      Choose One

      AgreedProposed

      Description

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Visitation Schedule YN

      Choose One

      AgreedProposed

      MONEY OWED TO EITHER HUSBAND OR WIFE

      Name of debtor

      Debtor's relationship to you

      Is debt evidenced in writing?

      YesNo

      Is debt secured?

      YesNo

      If so, with what is the debt secured?

      When was the money loaned?

      When is the debt due to be paid?

      How much was the original loan balance?

      Current loan amount owed as of

      (date)

      (amount)

      Name of debtor

      Debtor's relationship to you

      Is debt evidenced in writing?

      YesNo

      Is debt secured?

      YesNo

      If so, with what is the debt secured?

      When was the money loaned?

      When is the debt due to be paid?

      How much was the original loan balance?

      Current loan amount owed as of

      (date)

      (amount)

      Name of debtor

      Debtor's relationship to you

      Is debt evidenced in writing?

      YesNo

      Is debt secured?

      YesNo

      If so, with what is the debt secured?

      When was the money loaned?

      When is the debt due to be paid?

      How much was the original loan balance?

      Current loan amount owed as of

      (date)

      (amount)

      CONTINGENT ASSETS AND CLAIMS

      Description:

      Estimated Value

      Description:

      Estimated Value

      Description:

      Estimated Value

      ANY OTHER ASSETS

      Description

      Location

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Description

      Location

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Description

      Location

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Description

      Location

      Value

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Part 2

      CLAIMS OF ECONOMIC CONTRIBUTION/REIMBURSEMENT BY ONE SPOUSE TO THE OTHER

      Estate with claim

      Estate against which claim is made

      Nature of claim

      Value

      Estate with claim

      Estate against which claim is made

      Nature of claim

      Value

      Estate with claim

      Estate against which claim is made

      Nature of claim

      Value

      Estate with claim

      Estate against which claim is made

      Nature of claim

      Value

      Part 3
      UNSECURED COMMUNITY LIABILITIES

      CREDIT AND DEBIT CARDS AND CHARGE ACCOUNTS:

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Name and type of account

      Financial institution/issued by

      Account number

      Minimum monthly payment

      Name(s) on account

      Signatures on credit card application

      Name(s) of authorized users

      Balance transferred from

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      UNSECURED LOANS OWED TO OTHER PEOPLE:

      Loan payable to

      Loan made by

      Original loan amount

      Balance as of

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      Loan payable to

      Loan made by

      Original loan amount

      Balance as of

      (date)

      (balance)

      Choose One

      Award to HusbandAward to WifeSplit

      Choose One

      AgreedProposed

      FEDERAL, STATE AND LOCAL TAX LIABILITY:

      Entity owed

      Tax year

      WIFE
      Amount owed as of

      Entity owed

      Tax year

      HUSBAND
      Amount owed as of

      CONTINGENT LIABILITIES (e.g., lawsuits against either party, guaranty either party may have signed):

      Name of creditor

      Name of person primarily liable

      Guaranteed by

      Nature of contingency

      Amount of contingent liability

      WIFE

      HUSBAND

      OTHER LIABILITIES NOT PREVIOUSLY LISTED IN THIS INVENTORY

      Description

      Amount owed as of

      (date)

      (balance)

      Description

      Amount owed as of

      (date)

      (balance)

      Description

      Amount owed as of

      (date)

      (balance)

      Description

      Amount owed as of

      (date)

      (balance)

      Part 4
      TRUST, ESTATE, AND CUSTODIAL ASSETS

      ASSETS HELD BY EITHER PARTY FOR THE BENEFIT OF ANOTHER

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g., executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g., executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g., executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g., executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      ASSETS HELD BY ANOTHER FOR THE BENEFIT OF EITHER PARTY OR FOR THE CHILDREN

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g. executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      Name of person holding assets

      Description of assets

      Name and title of fiduciary (e.g. executor, trustee)

      Name of owner of beneficial interest

      Value of assets as of

      (date)

      (value)

      CUSTODIAL ACCOUNTS UNDER UNIFORM TRANSFERS TO MINORS ACT:

      Name of financial institution

      Type of account

      Name of account

      Account number

      Date account was opened

      Persons named on withdrawal cards

      Name of minor

      Account balance as of

      (date)

      (balance)

      Part 5
      SEPARATE PROPERTY AND SEPARATE LIABILITIES

      SEPARATE PROPERTY AND LIABILITIES OF WIFE:

      Description

      When Acquired

      How Acquired

      Estimated Value

      SEPARATE PROPERTY AND LIABILITIES OF HUSBAND:

      Description

      When Acquired

      How Acquired

      Estimated Value