Assets and Debts Questionnaire

Name

First Name Last Name

Date

Month Day Year

1) Real Estate - Please list each property, the date you acquired the property, the fair market value of the property, and the amount of debt owed on the property.

Send Hershon Law the following:

(a) Deeds showing the legal description of your home and other real estate owned by you and your spouse or registered domestic partner, individually or jointly.

(b) Mortgage or deed of trust showing amounts/balances owed on home and any other real estate and the last monthly mortgage payment statements.

(c) Tax Assessor’s statements on home and other real estate.

2) Household Furniture, Furnishings - Please list each piece of property, the date you acquired the property, the fair market value of the property, and the amount of debt owed on the property.

3) Jewelry, Antiques, Art - Please list each piece of property, the date you acquired the property, the fair market value of the property, and the amount of debt owed on the property.

4) Vehicles, Boats, Trailers - Please list each piece of property, the date you acquired the property, the fair market value of the property, and the amount of debt owed on the property.

Send Hershon Law the following:

Copies of pink slips and/or registration slips to all automobiles, other motor vehicles, boats, or trailers owned by you and/or your spouse or registered domestic partner, individually or jointly. If there are loans outstanding, copies of original loan papers and statement showing current balance. State who usually drives each vehicle.

5) Savings Accounts

Send Hershon Law a copy of statements for each account for the last year.

6) Checking Accounts

Send Hershon Law a copy of statements for each account for the last year.

7) Credit Union, Other Deposit Accounts

Send Hershon Law a copy of statements for each account for the last year.

8) Cash - List amount and location of any cash in possession ofyou and your spouse or registered domestic partner

9) Tax Refunds - (a) Is there a California or federal refund due you and yourspouse or registered domestic partner for the latest tax year? (b) If so, how much is each refund and to what address is it being sent?

10) Life Insurance with Cash Surrender or Loan Value - Current life insurance policies and loans againstsame. List them below, including names of agents

Send Hershon Law a copy of the declaration page for each policy and statement of loans.

11) Stocks, Bonds, Secured Notes, Mutual Funds - List names of brokers and account numbers

Send Hershon Law brokerage statements for the last year.

12) Retirement and Pensions

Send Hershon Law a copy of the latest summary plan documents and latest benefit statements.

13) Profit Sharing, Annuities, IRAs, Deferred Compensation

Send Hershon Law a copy of the latest plan documents and latest benefit statements.

14) Accounts Receivable and Unsecured Notes

Send Hershon Law a copy of each.

15) Partnerships and other Business Interests

Send Hershon Law copies of most recent K-1 form and Schedule C (from your taxes).

16) Other Assets

17) Student Loans

18) Taxes

19) Support Arrearages

Send Hershon Law copies of orders and statements.

20) Loans (Unsecured) - list bank and loan number

Send Hershon Law copies of the latest statements.

21) Credit Cards - note whether you or your spouse/domestic partner made the payments and continued to use the accounts after separation

Send Hershon Law copies of credit card statements since separation.

22) Other Debts

Send Hershon Law copies of promissory notes and IOUs.

23) Provide any other information that will help establish your net worth, the net worth of your spouse or registered domestic matter, your income, and the income of your spouse or registered domestic partner.

24) Provide a description of all gifts and inheritances to you and your spouse or registered domestic partner during the marriage or partnership, listing the recipient, the amounts, the source, and how these funds or items were spent to saved.

26) Provide a copy or explanation, or both, of medical or health insurance coverage.

27) Provide any written agreements with your spouse or registered domestic partner (premarital/prepartnership or after marriage or registration of the domestic partnership.

Assets and Debts Questionnaire

ASSETS

DEBTS

OTHER RELEVANT INFORMATION