Full name (including complete middle or maiden name):
Any other name, including any business name, in the last 8 years:
Social Security Number:
Cell Phone Number:
Home Telephone Number:
Work Telephone Number:
Email Address:
Complete Street Address:
Complete Mailing Address (if different):
Spouse's full name:
Spouse — any other name, incl. business name, in the last 8 years:
Spouse — Social Security Number:
Spouse — Cell Phone Number:
Spouse — Home Telephone Number:
Spouse — Work Telephone Number:
Spouse — Complete Street Address:
Spouse — Complete Mailing Address (if different):
If so, year filed:
Monthly $ — Rent / home mortgage payment (first mortgage):
Monthly $ — Real estate taxes:
Monthly $ — Property, homeowner's or renter's insurance:
Monthly $ — Home maintenance (repairs and upkeep):
Monthly $ — Homeowner's association or condominium dues:
Monthly $ — Additional mortgage payments (home equity / second mortgage):
Monthly $ — Utilities — electricity and/or gas:
Monthly $ — Utilities — water, sewer and garbage collection:
Monthly $ — Utilities — telephone, cell, internet, cable and satellite:
Monthly $ — Security alarm monitoring:
Monthly $ — Food and housekeeping supplies:
Monthly $ — Childcare / children's education costs:
Monthly $ — Clothing, laundry and dry cleaning:
Monthly $ — Personal care products and services:
Monthly $ — Medical and dental expenses and medicines (avg. monthly):
Monthly $ — Transportation (gas, car repairs — NOT car payments):
Monthly $ — Recreation, clubs, entertainment, newspapers, magazines:
Monthly $ — Charitable contributions:
Monthly $ — Insurance — Life:
Monthly $ — Insurance — Health:
Monthly $ — Insurance — Auto:
Monthly $ — Insurance — Other:
Monthly $ — Property taxes (vehicles, mobile home, land, house) if not in mortgage:
Monthly $ — Installment payment — Vehicle 1:
Monthly $ — Installment payment — Vehicle 2:
Monthly $ — Installment payment — Other:
Monthly $ — Alimony, maintenance and support paid to others:
Monthly $ — Support of additional dependents not living in your home:
Pet supplies — kind of pets and how many:
Monthly $ — Pet supplies:
Cash on hand — amount:
Cash on hand — ownership:
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W
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Checking account(s) — bank/credit union name, last 4 of acct #, and balance:
Checking — ownership:
H
W
J
Savings / Venmo / Cash App — name, last 4 of acct #, and balance:
Savings — ownership:
H
W
J
Safe deposit box — name of bank:
Safe deposit box — contents:
Security deposits held by utilities/landlords — name and address:
Security deposits — amount:
Retirement / IRA / Pension / Profit-sharing — company, plan type, balance, loan amount if any:
Retirement — ownership:
H
W
J
Life insurance — company and beneficiary:
Life insurance — monthly premium (if not wage deducted):
Life insurance — cash surrender value (if any):
Additional assets (guns, knives, campers, RVs, trailers, collections, etc.):
Additional assets — replacement value:
Ammo — type and how many rounds or boxes:
House(s) / land deeded in your name or jointly — address (incl. mobile home+land, burial plots):
House(s) / land — replacement value (NOT tax value):
House(s) / land — ownership:
H
W
J
Mobile home titled in your name or jointly — year, make, model, address:
Mobile home — value (NOT tax value):
Interest in estate, life estate, or item in probate court — description:
Estate / probate — value:
Stocks, bonds, annuities — description:
Stocks / bonds / annuities — value:
Vehicle(s) in your name or jointly — year, make, model, VIN, mileage:
Vehicle(s) — total value:
Vehicle(s) — ownership:
H
W
J
Boat(s) — year, make, model, length, motor type/HP, trailer type:
Boat(s) — value:
Motorcycle / 4-wheeler — year, make, model, mileage:
Motorcycle / 4-wheeler — value:
Money owed to you / accounts receivable — name and address of who owes you:
Money owed to you — amount:
Tools of trade (used to earn your living) — description:
Tools of trade — value:
Open or enclosed trailer(s) — description:
Open or enclosed trailer(s) — value:
Description and date sold/transferred; buyer's name & relationship (or how you found them); amount sold for / approx. payoff:
Including yourself, how many people live in your household full time?:
How many of those people are children?:
Age and sex (boy/girl) of each child:
Institution and type of account (checking, savings, retirement, etc.), date closed, and balance on the date closed:
Appliances (printers, washer, dryer, refrigerator, freezer, microwave):
Miscellaneous (dishes/china, cooking equipment, silverware, linens, sheets/towels/blankets):
Sporting goods (bicycles, camping, fishing, golf clubs, misc. equipment):
Collectibles (stamps/coins, figurines, sports memorabilia, comic books, misc.):
Music equipment (CDs/DVDs/music collections, equipment):
Clothing — total value:
Jewelry — description, quantity, estimated value:
Other property — description, quantity, estimated value:
If yes, name and address of who you rent from:
How long is your lease?:
How many months remaining?:
If yes, name and address of the person you pay support to:
Signature (type your full name):
Date:
Spouse signature (type full name, if joint):
Spouse date:
