Statement Of Information - Confidential Information For Your Protection Page 2

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SPOUSE’S/DOMESTIC PARTNER’S OCCUPATIONS/BUSINESSES (LAST 10 YEARS)
________________________________________________________________________________________________________
Firm or Business name
Address
From (date) to (date)
________________________________________________________________________________________________________
Firm or Business name
Address
From (date) to (date)
(If more space is required, use reverse side of form)
______________________________________________________________________________
PRIOR MARRIAGE(S)
Any prior marriages for either spouse? ____________________
If yes, complete the following:
Prior spouse’s name: ______________________________
Prior Spouse of Husband: ______________________________
Marriage terminated by: Death _____
Divorce _____
Date of termination: ____________________
Prior spouse’s name: ______________________________
Prior Spouse of Husband: ______________________________
Marriage terminated by: Death _____
Divorce _____
Date of termination: ____________________
(If more space is required, use reverse side of form)
______________________________________________________________________________
PRIOR DOMESTIC PARTNERSHIP(S)
Any prior domestic partnerships for either person? __________
If yes, complete the following:
Prior partner’s name: ______________________________
Prior Partner: ______________________________
Partnership terminated by: Death _____
Dissolution _____
Nullification _____
Termination _____
Date of termination: ____________________
Prior partner’s name: ______________________________
Prior Partner: ______________________________
Partnership terminated by: Death _____
Dissolution _____
Nullification _____
Termination _____
Date of termination: ____________________
(If more space is required, use reverse side of form)
______________________________________________________________________________
INFORMATION ABOUT THE PROPERTY
Buyer intends to reside on the property in this transaction: Yes __________
No __________
______________________________________________________________________________
OWNER TO COMPLETE THE FOLLOWING ITEMS
Street Address of Property in this transaction: __________________________________________________________________
The land is unimproved __________; or improved with a structure of the following type:
A Single or 1-4 Family __________
Condo Unit __________
Other ___________________________________________
Improvements, remodeling or repairs to this property have been made within the past six months: Yes _____
No _____
If yes, have all costs for labor and materials arising in connection therewith been paid in full? Yes _____
No _____
Any current loans on property? __________
If yes, complete the following:
Lender: ______________________________
Loan Amount: ____________________ Loan Date: ____________________
Lender: ______________________________
Loan Amount: ____________________ Loan Date: ____________________
The undersigned declare, under penalty of perjury, that the foregoing is true and correct
. If applicable, both spouses/domestic partners must sign.
Executed on _________________________, __________ at _______________________________________________________
Signature: ________________________________________
Signature: ________________________________________

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