IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI FAMILY COURT DIVISION AT KANSAS CITY AT INDEPENDENCE

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IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI FAMILY COURT DIVISION AT KANSAS CITY AT INDEPENDENCE IN RE THE MARRIAGE OF: ) ) ) Petitioner, ) Case No. and ) ) Division: ) Respondent. ) STATEMENT OF MARITAL AND NON-MARITAL ASSETS AND DEBTS OF MARITAL PROPERTY List all marital property in this section, rounding all figures to the nearest dollar. Marital Property means all property acquired by either spouse subsequent to the marriage except property: 1. Acquired by gift, bequest, devise or descent; 2. Acquired in exchange for property acquired prior to the marriage or in exchange for property acquired by gift, bequest, devise, or descent; 3. Acquired by a spouse after a decree of legal separation; 4. Excluded by valid agreement of the parties; and 5. The increase in the value of property acquired prior to the marriage or pursuant to 1 through 4 above unless marital assets including labor have contributed to such increases and then only to the extent of such contributions. (Section 452.330.2 R.S.Mo. 1988) A. Real Estate - List interests in real estate including leaseholds with address, legal description & name of lender. Fair Market Amount Owed Equity To Poss'n Legal: Lender: Legal: Lender:

B. MOTOR VEHICLES - List all automobiles, boats, trailers, aircraft, recreational vehicles and campers. List year, make, model, vehicle identification number. List leasehold interests also. Fair Market Amount Owed Equity To Poss'n VIN. VIN. VIN. VIN. C. BANK ACCOUNTS - List all checking, saving and money market accounts, certificates of deposit, etc. held in your name alone or with another person. Give the name of the institution, the names on the account, the account number and current balance. D. SECURITIES - List all stocks, including both public and closely held corporations, bonds, promissory notes, mortgages, money market funds, mutual funds, etc. List the names in which the securities are held and the identification number, if any. E. WHOLE/UNIVERSAL LIFE INSURANCE - List the type of policy, name of issuing company, policy number, owner, insured, beneficiaries, face value and cash value (include policies from employment). F. TERM LIFE INSURANCE - List the type of policy, name of issuing company, policy number, owner, insured, beneficiaries, face value and cash value, if any. (Include policies from employment). Fair Market Amount Owed Equity To Poss'n

G. RETIREMENT, PENSION AND/OR PROFIT SHARING - List company, plan and participant's names, percent vested and present total value. H. DEBTS OWED TO YOU - List debtor's name and due date I. SOLE PROPRIETORSHIPS, PARTNERSHIPS OR JOINT VENTURES - List the percent interest owned. J. CLAIMS OR LAWSUITS AGAINST OTHERS - List the reason for the claim, sufficient information to identify it, against whom and for what, and any court proceedings, including attorney names. K. CASH ON HAND L. HOUSEHOLD AND PERSONAL GOODS - List all household and personal goods, including appliances, furniture, silver, antiques, collections, tools, etc. Specify items on Exhibit 1 and list totals here. 1. Party s Proposal of Assets to Self $ 2. Party's Proposal of Assets to Spouse $ M. OTHER ASSETS - List all assets not already listed such as trust interests and stock options. Fair Market Amount Owed Equity To Poss'n

NON-MARITAL PROPERTY - List all non-marital property here. See definition of marital property on page 1. ITEM PRESENT VALUE AMOUNT OWED EQUITY ALLEGED OWNER

DEBTS - List all debt, including loans from banks, credit unions, savings and loan associations or other lending institutions, credit card balances and store charges. State name of lender and debtor. CREDITOR CURRENT BALANCE SECURED YES/NO MTHLY PYM'T LIABILITY INCURRED BY: H/W/J WHO SHOULD PAY H/W AFFIDAVIT I certify that the above Statement of Marital and Non-Marital Assets and Debts is complete, true and accurate to the best of my knowledge and belief. Affiant Subscribed and sworn to before me the undersigned Notary Public, on. My Commission Expires: Notary Public

Household Goods and Personal Goods Exhibit 1 Items To Wife - Currently in Wife s Possession: Item TOTAL: Household Goods and Personal Goods Items To Wife - Currently in Husband s Possession:

TOTAL: Item

Household Goods and Personal Goods Items To Husband - Currently in Husband s Possession Item TOTAL:

Household Goods and Personal Goods Items To Husband - Currently in Wife s Possession: Item TOTAL:

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