Appendix V - Family Part Case Information Statement Form Page 8
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10Part E - Balance Sheet of All Family Assets and Liabilities
Statement of Assets
Date of purchase/acquisition.
Title to
Date of
If claim that asset is exempt,
Value $
Description
Property
Evaluation
state reason and value of
Put * after exempt
(P, D, J)
1
Mo./Day/ Yr.
what is claimed to be exempt
1. Real Property
2. Bank Accounts, CD’s (identify institution and type of account(s))
3. Vehicles
4. Tangible Personal Property
5. Stocks, Bonds and Securities (identify institution and type of account(s))
6. Pension, Profit Sharing, Retirement Plan(s), 40l(k)s, etc. (identify each institution or employer)
7. IRAs
8. Businesses, Partnerships, Professional Practices
9. Life Insurance (cash surrender value)
10. Loans Receivable
11. Other (specify)
TOTAL GROSS ASSETS:
$
TOTAL SUBJECT TO EQUITABLE DISTRIBUTION:
$
TOTAL NOT SUBJECT TO EQUITABLE DISTRIBUTION:
$
1
P = Plaintiff; D = Defendant; J = Joint
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
Page 8 of 10
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