Case No.____________________________________
Petitioner Respondent
Value
Real estate located at:
$_____________
Legal Description: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Petitioner Respondent
Value
Real estate located at:
$_____________
Legal Description: ________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Household furniture and appliances:
Petitioner Respondent
Value
________________________________
$
________________________________
$
________________________________
$
________________________________
$
________________________________
$
________________________________
$
Household furnishings:
Petitioner Respondent
Value
________________________________
$
________________________________
$
________________________________
$
________________________________
$
________________________________
$
________________________________
$
Other items:
Petitioner Respondent
Value
________________________________
$
________________________________
$
________________________________
$
________________________________
$
Pension/retirement fund/profit sharing/stock plan/401K:
Petitioner Respondent
Value
________________________________
$
________________________________
$
________________________________
$
________________________________
$
________________________________
$
Motor vehicles:
Petitioner Respondent
Value
Make__________________________
$_____________
Model _________________________
VIN ___________________________
Lien Holder _____________________
Page 3 of 8
Revised: 7/22/2015