Financial Data Entry Sheet for Net Worth Statement

Financial Data Entry Sheet for Net Worth Statement Your name: Spouse s name: I. FAMILY DATA Your birth date: Spouse s birth date: Spouse s place of birth: Spouse s Social Security number: Date married: Place married (city, county, state): Date separated or divorced: Children of marriage: Child s Name Birth Date Minor Children of a prior marriage: Child Name Birth Date Custody Tax Exemption 1

(Husband/Wife/Joint) (Husband/Wife/Neither) Your present address: Spouse's present address: Your occupation: Your employer's name: Your employer s address: Spouse s occupation: Spouse s employer's Name Spouse s employer address: II. INCOME & EXPENSES 2

Wages Yourself: per [week / biweekly / semi-monthly / month / year] [ ] Is this self-employment income? [ ] Does New York City tax apply? [ ] Does Yonkers tax surcharge apply? Spouse: per [week / biweekly / semi-monthly / month / year] [ ] Is this self-employment income? [ ] Does New York City tax apply? [ ] Does Yonkers tax surcharge apply? Your Wage-Like Income Note: Enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Weekly Monthly Annual Child support from previous relationship Spousal maintenance from previous relationship Unemployment compensation Public assistance Bonuses Commissions Tips Overtime Disability benefits Workers compensation Royalties Rent from spouse Deferred compensation Income from a new spouse Social security benefits received 3

Supplemental Security Income Food stamps Veterans benefits Other: For the Income Worksheet Employed child If any child or other member of your household is employed, state the person s name(s) and annual income(s). Support and Maintenance received List any maintenance and/or child support you are receiving pursuant to court order or agreement. If you are using the prior year s tax return to report income (ask your attorney, mediator, accountant, or financial professional), then continue with these entries. Otherwise, skip this section: (a) Gross income from most recent tax return. (b) Income not included in Gross income 1. Tax-exempt investment income, reduced by sums expended in connection with that investment. 2. Worker s Compensation (if not included above) (this is usually taxable and would have been included above). Percentage of amount due to lost wages: % 4

3. Disability benefits (if not included above) Percentage of amount due to lost wages: % 4. Unemployment insurance benefits (if not included above) (this is usually taxable and would have been included above). 5. Social Security benefits (A portion is typically taxable. Include the taxfree portion.) 6. Supplemental Security Income 7. Public assistance 8. Food stamps 9. Veterans benefits 10. Pensions and retirement benefits. (These are usually taxable and would have been included above.) 11. Fellowships and stipends 12. Annuity payments. (A portion is typically taxable. Include the taxfree portion.) II. EXPENSES: (enter each expense weekly OR monthly OR annually) Real Estate Property #1: (Including real property, leaseholds, life estates, etc.) Location and Value: Address Current Market Value: First mortgage: Current balance: monthly payment (princ and int only*) 5

Annual interest rate: % Who is paying: First mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: Second mortgage or home equity line: Current balance: monthly payment (princ and int only*) Annual interest rate: % Who is paying: Second mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: Additional information: Title is in whose name: Date of acquisition of property: Original price: Source of funds to acquire: Your separate amount: Spouse s separate amount: If a rental income property, monthly income * Princ and int only. Please put the principal + interest only. Do not include taxes, homeowners insurance, or any other charges. Please enter those other charges below. Real estate expense information: 6

Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Household Expenses: Weekly Monthly Annually 1. Real Estate Taxes 2. Homeowner s / Renter s Insurance 3. Homeowner's Assoc. / Condo Charge 4. Rent 5. Other Housing 6. Fuel Oil/Gas 7. Electric 8. Telephone (land line) 9. Mobile Phone 10. Cable / Satellite TV 11. Internet 12. Alarm 13. Water 14. Other Utilities 15. Repairs 16. Painting Wallpapering 17. Gardening / Landscaping 18. Sanitation / Carting 19. Snow Removal 20. Extermination 21. Other Maintenance Real Estate Property #2: (Including real property, leaseholds, life estates, etc.) 7

Location and Value: Address Current Market Value: First mortgage: Current balance: monthly payment (princ and int only*) Annual interest rate: % Who is paying: First mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: Second mortgage or home equity line: Current balance: monthly payment (princ and int only*) Annual interest rate: % Who is paying: Second mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: Additional information: Title is in whose name: Date of acquisition of property: Original price: Source of funds to acquire: 8

Your separate amount: Spouse s separate amount: If a rental income property, monthly income * Princ and int only. Please put the principal + interest only. Do not include taxes, homeowners insurance, or any other charges. Please enter those other charges below. Real estate expense information: Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Household Expenses: Weekly Monthly Annually 1. Real Estate Taxes 2. Homeowner s / Renter s Insurance 3. Homeowner's Assoc. / Condo Charge 4. Rent 5. Other Housing 6. Fuel Oil/Gas 7. Electric 8. Telephone (land line) 9. Mobile Phone 10. Cable / Satellite TV 11. Internet 12. Alarm 13. Water 14. Other Utilities 15. Repairs 16. Painting Wallpapering 17. Gardening / Landscaping 18. Sanitation / Carting 9

19. Snow Removal 20. Extermination 21. Other Maintenance Real Estate Property #3: (Including real property, leaseholds, life estates, etc.) Location and Value: Address Current Market Value: First mortgage: Current balance: monthly payment (princ and int only*) Annual interest rate: % Who is paying: First mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: Second mortgage or home equity line: Current balance: monthly payment (princ and int only*) Annual interest rate: % Who is paying: Second mortgage information for Liabilities page: Mortgagor (name on mortgage): Original debt: Date of incurring debt. Maturity date: 10

Additional information: Title is in whose name: Date of acquisition of property: Original price: Source of funds to acquire: Your separate amount: Spouse s separate amount: If a rental income property, monthly income * Princ and int only. Please put the principal + interest only. Do not include taxes, homeowners insurance, or any other charges. Please enter those other charges below. Real estate expense information: Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Household Expenses: Weekly Monthly Annually 1. Real Estate Taxes 2. Homeowner s / Renter s Insurance 3. Homeowner's Assoc. / Condo Charge 4. Rent 5. Other Housing 6. Fuel Oil/Gas 7. Electric 8. Telephone (land line) 9. Mobile Phone 10. Cable / Satellite TV 11. Internet 12. Alarm 11

13. Water 14. Other Utilities 15. Repairs 16. Painting Wallpapering 17. Gardening / Landscaping 18. Sanitation / Carting 19. Snow Removal 20. Extermination 21. Other Maintenance Your other expenses: Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Your Food Groceries Child Groceries Dining Out / Take Out Other Food Your clothing expenses: Clothing Yourself Clothing Child(ren) Dry Cleaning Other Clothing Your insurance expenses Fire, Theft, Liability Insurance 12

Automotive Insurance Umbrella Insurance Medical Plan Name of carrier: Who is the primary insured person: Child Medical Plan Dental Plan Optical Plan Disability Worker's Comp Long Term Care Other Insurance Your unreimbursed medical expenses Adult medical Child medical Adult dental Child dental Adult optical Child optical Adult medication Child medication Surgical, nursing, hospital 13

Psychotherapy Other medical Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Your household help Domestic (housekeeper, etc.). Nanny/au pair/child care Babysitter Other help Your automobile expenses Lease or loan payments Lease term: Gas and oil Repairs Car wash Parking Tolls Other Your education costs Note: Please enter primary, secondary, and college costs in the major expenses, section (below), not here. Nursery and preschool Religious instruction School transportation School books Lessons and supplies 14

School lunches Tutoring School events Children activities Other education Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Your recreational expenses Adult vacations Child vacations Movies, theater, ballet, etc. Music (digital or physical media) Recreations, clubs and memberships Activities for yourself Health club Summer camp Birthday party costs for children Other recreational Your miscellaneous expenses Beauty parlor/barber/spa Children s grooming Toiletries/nonprescription drugs Books, magazines, newspapers Gifts to others Charitable contributions 15

Religious organization dues Union and organization dues Commuting expenses Veterinarian/pet expenses Previous relationship child support Previous relationship maintenance (alimony) Employment unreimbursed travel Employment unreimbursed education Employment uniforms Safe deposit box rental fee Note: For all expenses, enter an amount in only one column (weekly, or monthly, or annual), whichever is easiest for you. Your other expenses 16

Major expenses (primary and secondary education, college, camps) for you, spouse, and children: Description Start year # of years Annual cost today % of cost you are paying 17

IV. ASSETS: Cash Account a. Location b. Source of funds c. Amount as of date of commencement d. Current amount d1. Your separate property amount d2. Spouse s separate property amount Cash Account e. Location f. Source of funds g. Amount as of date of commencement h. Current amount d1. Your separate property amount d2. Spouse s separate property amount Checking Account a. Financial institution b. Account number c. Title holder d. Date opened e. Source of funds f. Balance as of date of commencement g. Current balance 18

more info h. Income currently received, if any Checking Account a. Financial institution b. Account number c. Title holder d. Date opened e. Source of funds f. Balance as of date of commencement g. Current balance more info h. Income currently received, if any Checking Account a. Financial institution b. Account number c. Title holder d. Date opened e. Source of funds 19

f. Balance as of date of commencement g. Current balance more info h. Income currently received, if any Savings Accounts (including individual, joint, totten trust, certificates of deposit, and treasury notes). a. Financial institution b. Account number c. Title owner d. Type of account e. Date opened f. Source of funds g. Balance as of date of commencement h. Current balance h1. Your separate property amount h2. Spouse s separate property amount more info i. Income currently received, if any Savings Accounts (including individual, joint, totten trust, certificates of deposit, and treasury notes). a. Financial institution 20

b. Account number c. Title owner d. Type of account e. Date opened f. Source of funds g. Balance as of date of commencement h. Current balance h1. Your separate property amount h2. Spouse s separate property amount more info i. Income currently received, if any IRA and Pension Retirement assets (IRA, 401(k), 403(b), profit sharing plans, deferred compensation plans, and other defined contribution plans) a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info 21

h. Income currently received, if any i. Your annual contribution to account j. Your spouse s annual contribution to account IRA and Pension Retirement assets (IRA, 401(k), 403(b), profit sharing plans, deferred compensation plans, and other defined contribution plans) a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info h. Income currently received, if any i. Your annual contribution to account j. Your spouse s annual contribution to account IRA and Pension Retirement assets (IRA, 401(k), 403(b), profit sharing plans, deferred compensation plans, and other defined contribution plans) a. Description b. Location of assets c. Title owner d. Date of acquisition 22

e. Source of funds f. Value as of date of commencement g. Current value more info h. Income currently received, if any i. Your annual contribution to account j. Your spouse s annual contribution to account IRA and Pension Retirement assets (IRA, 401(k), 403(b), profit sharing plans, deferred compensation plans, and other defined contribution plans) a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info h. Income currently received, if any i. Your annual contribution to account 23

j. Your spouse s annual contribution to account IRA and Pension Retirement assets (IRA, 401(k), 403(b), profit sharing plans, deferred compensation plans, and other defined contribution plans) a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info h. Income currently received, if any i. Your annual contribution to account j. Your spouse s annual contribution to account Defined benefit pension plans a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds 24

f. Value as of date of commencement g. Current value more info h. Retirement date (benefit start date) i. Benefit amount per month (anticipated or, if retired, being received). j. Cost of living adjustment, if any (%). k. Benefit assumes employee works until what date? (Please state cut-off date, or retirement date. ) % Defined benefit pension plans a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info h. Retirement date (benefit start date) i. Benefit amount per month (anticipated or, if retired, being 25

received). j. Cost of living adjustment, if any (%). k. Benefit assumes employee works until what date? (Please state cut-off date, or retirement date. ) % Defined benefit pension plans a. Description b. Location of assets c. Title owner d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value more info h. Retirement date (benefit start date) i. Benefit amount per month (anticipated or, if retired, being received). j. Cost of living adjustment, if any (%). k. Benefit assumes employee works until what date? (Please state cut-off date, or retirement date. ) % Vehicles (Auto, Boat, Truck, Plane, Camper, Motorcycles, etc.) a. Description, year, make and model. 26

Personal or business? b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of lien unpaid g. Current fair market value h. Value as of date of commencement Vehicles (Auto, Boat, Truck, Plane, Camper, Motorcycles, etc.) a. Description, year, make and model. Personal or business? b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of lien unpaid g. Current fair market value 27

h. Value as of date of commencement Vehicles (Auto, Boat, Truck, Plane, Camper, Motorcycles, etc.) a. Description, year, make and model. Personal or business? b. Title owner c. Date of acquisition d. Original price e. Source of funds to acquire f. Amount of lien unpaid g. Current fair market value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value 28

e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets 29

d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner 30

c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description 31

b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). 32

a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement Jewelry, art, antiques, household furnishings, precious objects, gold and precious metals (only if valued at more than 500). a. Description b. Title owner c. Location of assets d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Estimate current value h. Value as of date of commencement 33

Interest in a business a. Name and address of business b. Type of business (corporate, partnership, sole proprietorship, LLP, LLC, etc.) c. Your percentage of interest d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Net worth of business h. Other relevant information more info i. Net annual cash flow Interest in a business a. Name and address of business b. Type of business (corporate, partnership, sole proprietorship, LLP, LLC, etc.) c. Your percentage of interest 34

d. Date of acquisition e. Original price or value f. Source of funds to acquire g. Net worth of business h. Other relevant information more info i. Net annual cash flow Cash surrender value of life insurance a. Insurer s name and address: b. Name of insured c. Policy number d. Face amount of policy e. Policy owner f. Date of acquisition g. Source of funds h. Cash surrender value as of date of commencement 35

i. Current cash surrender value i2. Your separate property amount i3. Spouse s separate property amount i4. Your annual insurance premium i5. Spouse s annual insurance premium Cash surrender value of life insurance a. Insurer s name and address: b. Name of insured c. Policy number d. Face amount of policy e. Policy owner f. Date of acquisition g. Source of funds h. Cash surrender value as of date of commencement i. Current cash surrender value i2. Your separate property amount i3. Spouse s separate property amount i4. Your annual insurance premium i5. Spouse s annual insurance premium 36

Cash surrender value of life insurance a. Insurer s name and address: b. Name of insured c. Policy number d. Face amount of policy e. Policy owner f. Date of acquisition g. Source of funds h. Cash surrender value as of date of commencement i. Current cash surrender value i2. Your separate property amount i3. Spouse s separate property amount i4. Your annual insurance premium i5. Spouse s annual insurance premium Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder 37

c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info 38

h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds 39

f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment 40

Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value 41

g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description 42

a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value g3. Investment type more info h. Annual income from investment Investment accounts/securities/stock options/commodities/broker margin accounts a1. Description a2. Account number b. Title holder c. Location d. Date of acquisition e. Source of funds f. Value as of date of commencement g. Current value 43

g3. Investment type more info h. Annual income from investment Loans to others and Accounts Receivable a. Debtor s name and address b. Original amount of loan or debt c. Funds source/debt origin d. Date payment(s) due e. Amount due as of date of commencement. f. Current amount due f1. Your separate property amount f2. Spouse s separate property amount more info g. Monthly payment h. Annual interest rate Loans to others and Accounts Receivable b. Debtor s name and address 44

b. Original amount of loan or debt c. Funds source/debt origin d. Date payment(s) due e. Amount due as of date of commencement. f. Current amount due f1. Your separate property amount f2. Spouse s separate property amount more info g. Monthly payment h. Annual interest rate Contingent interests (stock options, interest subject to life estates, prospective inheritances) a. Description b. Location c. Date of vesting d. Title owner e. Date of acquisition f. Original price or value g. Source of funds to acquire h. Method of valuation i. Value as of date of commencement j. Current value 45

j1. Your separate property amount j2. Spouse s separate property amount Contingent interests (stock options, interest subject to life estates, prospective inheritances) a. Description b. Location c. Date of vesting d. Title owner e. Date of acquisition f. Original price or value g. Source of funds to acquire h. Method of valuation i. Value as of date of commencement j. Current value j1. Your separate property amount j2. Spouse s separate property amount Contingent interests (stock options, interest subject to life estates, prospective inheritances) a. Description b. Location c. Date of vesting d. Title owner e. Date of acquisition f. Original price or value g. Source of funds to acquire 46

h. Method of valuation i. Value as of date of commencement j. Current value j1. Your separate property amount j2. Spouse s separate property amount Other Assets (e.g. tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other assets not itemized above) a. Description b. Title holder c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Value as of date of commencement h. Current value h1. Your separate property amount h2. Spouse s separate property amount Other Assets (e.g. tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other assets not itemized above) a. Description b. Title holder c. Location d. Original price or value e. Source of funds to acquire 47

f. Amount of lien unpaid g. Value as of date of commencement h. Current value h1. Your separate property amount h2. Spouse s separate property amount Other Assets (e.g. tax shelter investments, collections, judgments, causes of action, patents, trademarks, copyrights, and any other assets not itemized above) a. Description b. Title holder c. Location d. Original price or value e. Source of funds to acquire f. Amount of lien unpaid g. Value as of date of commencement h. Current value h1. Your separate property amount h2. Spouse s separate property amount V. LIABILITIES Accounts Payable a. Description: Name and address of creditor: 48

b. Debtor c. Amount of original debt d. Date of incurring debt (may be various ) e. Purpose of debt f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no) Accounts Payable a. Description: Name and address of creditor: b. Debtor c. Amount of original debt d. Date of incurring debt (may be various ) e. Purpose of debt f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt 49

a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) 50

d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of 51

commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) 52

Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Credit Card Debt a. Debtor b. Amount of original debt 53

c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Note: Mortgage payable information is entered near the top of this document, with Real Estate properties. Notes Payable a. Description. Name and address of noteholder b. Debtor c. Amount of original debt d. Date of incurring debt (may be various ) e. Purpose of debt f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no) 54

Notes Payable a. Description. Name and address of noteholder b. Debtor c. Amount of original debt d. Date of incurring debt (may be various ) e. Purpose of debt f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no) Notes Payable a. Description. Name and address of noteholder b. Debtor c. Amount of original debt d. Date of incurring debt (may be various ) e. Purpose of debt 55

f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no) Brokers Margin Accounts a. Description. Name and address of broker b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Brokers Margin Accounts a. Description. Name and address of broker 56

b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) Brokers Margin Accounts a. Description. Name and address of broker b. Amount of original debt c. Date of incurring debt (may be various ) d. Purpose of debt e. Monthly or other periodic payment f. Amount of debt as of date of commencement g. Current amount of debt Is this a separate debt (yes or no) 57

Taxes Payable a. Description of tax c. Amount of tax Debtor: c. Date due Is this a separate debt (yes or no) Taxes Payable a. Description of tax d. Amount of tax Debtor: c. Date due Is this a separate debt (yes or no) Loans on Life Insurance Policies a. Description. Name and address of insurer b. Amount of loan c. Date of incurring debt (may be various ) d. Purpose of debt 58

e. Name of borrower f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no)? Loans on Life Insurance Policies a. Description. Name and address of insurer b. Amount of loan c. Date of incurring debt (may be various ) d. Purpose of debt e. Name of borrower f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no)? Loans on Life Insurance Policies a. Description. 59

Name and address of insurer b. Amount of loan c. Date of incurring debt (may be various ) d. Purpose of debt e. Name of borrower f. Monthly or other periodic payment g. Amount of debt as of date of commencement h. Current amount of debt Is this a separate debt (yes or no)? Installment accounts payable (security agreements, chattel mortgages ) a. Description Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose of debt f. Monthly or periodic payment 60

g. Amount of debt as of date of commencement h. Amount of current debt Is this a separate debt (yes or no)? Installment accounts payable (security agreements, chattel mortgages ) a. Description Name and address of creditor b. Debtor c. Amount of original debt d. Date of incurring debt e. Purpose of debt f. Monthly or periodic payment g. Amount of debt as of date of commencement h. Amount of current debt Is this a separate debt (yes or no)? Installment accounts payable (security agreements, chattel mortgages ) a. Description Name and address of creditor b. Debtor 61

c. Amount of original debt d. Date of incurring debt e. Purpose of debt f. Monthly or periodic payment g. Amount of debt as of date of commencement h. Amount of current debt Is this a separate debt (yes or no)? Other liabilities a. Description Name and address of creditor: c. Debtor d. Amount of original debt e. Date of incurring debt f. Purpose of debt g. Monthly payment h. Amount of debt as of date of commencement i. Amount of current debt Is this a separate debt (yes or no)? Other liabilities b. Description Name and address of creditor: 62

c. Debtor d. Amount of original debt e. Date of incurring debt f. Purpose of debt g. Monthly payment h. Amount of debt as of date of commencement i. Amount of current debt Is this a separate debt (yes or no)? Other liabilities c. Description Name and address of creditor: c. Debtor d. Amount of original debt e. Date of incurring debt f. Purpose of debt g. Monthly payment h. Amount of debt as of date of commencement i. Amount of current debt Is this a separate debt (yes or no)? 63

CLIENT SIGNATURE Signature: Date: 64