IN THE JUDICIAL CIRCUIT COURT OF COUNTY AT, MISSOURI In Re The Marriage Of:, Petitioner, Case No. And Division, Respondent. STATEMENT OF MARITAL AND NON-MARITAL PROPERTY AND LIABILITIES OF (FORM 68.4A [ ] Petitioner [ ] Respondent (Name of Party (Social Security # Instructions: Pursuant to Local Rule 68.4, this statement must be completed and executed under oath by each party in all contested actions for Dissolution of Marriage or Legal Separation. The completed statement shall be filed with the Court and supplied to the opposing party no later than five (5 days prior to the date of hearing. This statement shall be updated immediately if any changes occur after filing and prior to the date of hearing. Failure to file this statement in compliance with Local Rule 68.4 shall result in the imposition of sanctions pursuant to Rule 68.4(e I. MARITAL PROPERTY: Pursuant to Section 452.330.2, RSMo., "marital property" means all property acquired by either spouse subsequent to the marriage except: (1 Property acquired by gift, bequest, devise or descent; (2 Property acquired in exchange for property acquired prior to the marriage or in exchange for property acquired by gift, bequest, devise, or descent; (3 Property acquired by a spouse after a decree of legal separation; (4 Property excluded by valid written agreement of the parties; and (5 The increase in the value of property acquired prior to the marriage or pursuant to subdivisions (1 to (4 of this subsection unless marital assets including labor have contributed to such increases and then only to the extent of such contributions. I. MARITAL PROPERTY 1
A. REAL ESTATE: List interests in real estate including leaseholds. Include address, legal description and name of mortgagor and Lessor(s, if any. Address: Legal: Lender: B. MOTOR VEHICLES: Include all automobiles, boats, trailers, aircraft, recreational vehicles, & campers. List year, make, model, vehicle identification number & names of mortgagor(s, if any. C. BANK ACCOUNTS: List all checking and savings accounts, time deposits, certificates of deposit, money market certificates, etc., held in your name alone or in your name and another person's. Give the name of the institution, the name(s on the account and the account number. 2
D. CASH ON HAND: E. SECURITIES: List all stocks, including both public & closely held corporations, bonds, promissory notes, mortgages, money market funds and all other such property in which you have an interest. Give the names in which the securities are held and identification number, if any. F. LIFE INSURANCE: List the type of policy, name of issuing company, policy number, owner of policy, insured, beneficiaries, face value & cash value (include policies furnished by your employer. CASH SURRENDER VALUE OWED 3
G. HOUSEHOLD GOODS & PERSONAL GOODS: List all household goods & personal goods, including all appliances, furniture, silver, antiques, televisions, stereos, clothing, jewelry, furs, cameras, coin & stamp collections, tools, etc., in the following format: 4
H. RETIREMENT, PENSION AND/OR PROFIT SHARING: List name of company, date benefits began accruing, present percentage of benefits vested, present market value, and date when and amount of benefit payable at retirement based on present employment. I. INTERESTS IN TRUSTS: List any interest in a trust. Give name of the trust, name of trustee, settlor, beneficiaries, nature of the interest you have in the trust & attach to this statement a copy of the trust instrument. J. INTERESTS IN CONTRACTS MADE AND NOT PERFORMED: List the parties to the contract, your interest in the contract & the expected date of performance, if any. K. INTERESTS IN PENDING LITIGATION OR SUIT NOT YET FILED. 5
L. INTERESTS IN FARM EQUIPMENT, CROPS & ANIMALS: List the nature of the property and location. M. DEBTS OWED TO YOU BY OTHERS: List the name of the debtor, any security, date of loan and due date, if any. N. INTERESTS IN SOLE PROPRIETORSHIPS, PARTNERSHIPS, OR JOINT VENTURES: List the name of company and percentage of interest you hold. Attach itemized inventory, including valuations, of assets of company, & copy of any partnership or joint venture agreement. O. OTHER ASSETS: List all assets not already listed herein. 6
FUTURE INTERESTS- if you are heir to a pending probate estate, the beneficiary under a Beneficiary Deed, designated as the payee on the death of another on a bank account or the transferee on the death of another on a title to a vehicle, please list the interest you hold, the property in which you have an interest and the present owner of said property. P. FUTURE INTERESTS VALUE OWED DATE ACQUIRED ALLEGED OWNER II. NON-MARITAL PROPERTY: See definition of marital property on page 1. For each item of non-marital property, indicate how acquired. A. Real Estate List any and all interests held in real property (including address, legal description, name of mortgagor, how titled and when acquired. REAL ESTATE VALUE OWED DATE ACQUIRED ALLEGED OWNER 7
PERSONAL PROPERTY VALUE OWED DATE ACQUIRED ALLEGED OWNER III. LIABILITIES: List all loans from any bank, credit union, savings and loan association or other lending institution and indicate who signed the loan, the date of the loan, purpose of the loan, actual disposition of the proceeds and the name and address of the lender. List all credit card balances, store charges, and whose name is on the credit card. Also, list all other indebtedness and give the name and address of the creditor. LIABILITIES CURRENT BALANCE SECURED YES NO MONTHLY PAYMENT INCURRED BY JOINT AFFIDAVIT 8
STATE OF MISSOURI ss. COUNTY OF I,, the undersigned, being of lawful age and duly sworn, state that I have read the foregoing Statement of Marital and Non-Marital Property and Liabilities, and that it is complete, true and correct according to my best knowledge and belief., Affiant Subscribed and sworn to before me this day of 2014. My Commission expires: Notary Public 9