STATE OF MAINE
❐ PLAINTIFF’S ❐ DEFENDANT’S
This Financial Statement consists of three parts: Part I, General Statement; Part II, Inventory of Assets and Debts; and Part III,
Expenses. You must complete Parts I and II. Complete Part III only if alimony or attorney fees are involved. In each section, number
the items you list. If you need additional space, attach the information, and identify all attachments by completing the information
requested below. If there is a minor child/are minor children involved, check here ❐ and complete a Child Support Affidavit, form
The original of this Financial Statement signed by the party must be filed with the Court and a copy provided to the other party within
21 days of the Family Division Scheduling Order or before mediation, whichever is earlier. See M.R.Civ.P. 108(c). If a party fails to
file a Financial Statement as required by the rules, the Court may make such orders in regard to such failure as are just,
including but not limited to imposing sanctions as set forth in M.R.Civ.P. 37(b)(2). See M.R.Civ.P. 108(f).
I make this Financial Statement based on my personal knowledge, information and belief. It consists of the following:
Parts I and II. (Check this box if neither alimony nor attorney fees are involved.)
III. (Check this box if alimony and/or attorney fees are involved.)
This Financial Statement includes attachments for each of the following sections of Part II:
and attachments for each of the following sections of Part III:
I have furnished the opposing party a copy of this Financial Statement and the following:
A copy of each of the federal income tax returns I have filed for the last two tax years (if I do not have copies to furnish
the opposing party, I shall take steps to get them and will furnish them as soon as I receive them), and
A copy of each of the last three pay stubs I have received this year.
This Financial Statement is complete and is based on my personal knowledge, information, and belief, and to the extent it is based on
information, I believe such information to be true.
Personally appeared the above named ❐ plaintiff ❐ defendant and made oath to the foregoing.
❐ Notary Public ❐ Attorney
PART I. GENERAL STATEMENT
In this case, the following categories of property and property interests are involved. (Check all items that apply.)
A. Real Estate
❐ E. Stocks, bonds, and other securities
❐ F. Life and disability insurance
C. Tangible personal property (Household furniture
❐ G. Business interests
and furnishings, jewelry, art objects, antiques, tools,
❐ H. Other assets (Any assets not listed in any other
recreation equipment, etc.)
D. Cash, bank accounts, pensions, and retirement accounts
❐ I. Debts (Personal and business debts, credit card
payments, unpaid medical expenses, and other debts
whether or not secured by lien or mortgage.)
Pursuant to M.R.Civ.P. 108(d)(3), the information on this form is not subject to public inspection.
FM-043, Rev. 10/10