400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 2 of 7
SUMMARY OF
ASSETS
Check each box that applies to you or the other party
REAL
ESTATE
:
(primary residence,
camps, land,
timeshares,
etc.)
I have an interest in (own) real estate either
individually
or jointly with another. ☐
Yes ☐ No
The other party has/may have an interest in (own) real estate either
individually
or jointly with another. ☐
Yes ☐ No
PERSONAL PROPERTY
:
(furniture, antiques, jewelry, electronics,
etc.)
I own personal property
☐
Yes ☐ No
The other party owns/may own personal property
☐
Yes ☐ No
VEHICLES
:
(cars,
trucks, ATV's, boats, motorcycles, campers,
etc.)
I own vehicles either
individually
or jointly.
☐
Yes ☐ No
The other party owns/may own vehicles either individually or jointly ☐
Yes ☐ No
BANK
ACCOUNTS:
I have bank accounts either
individually
or jointly.
☐
Yes ☐ No
The other party has/may have bank accounts either individually or jointly. ☐
Yes ☐ No
INVESTMENTS
:
(stocks, bonds, mutual funds, trusts,
annuities)
I own investments either
individually
or jointly.
☐
Yes ☐ No
The other party owns/may own investments either individually or jointly. ☐
Yes ☐ No
RETIREMENT ACCOUNTS
(IRA,
401 K,
pensions, deferred compensation,
etc.)
I own retirement accounts.
☐
Yes ☐ No
The other party owns/may own retirement accounts. ☐
Yes ☐ No
LIFE INSURANCE POLICIES:
I have life insurance. ☐
Yes ☐ No
The other party has/may have life insurance. ☐
Yes ☐ No
BUSINESSES:
I own or have an ownership interest in a business.
☐
Yes ☐ No
The other party owns/may own an interest in a business.
☐
Yes ☐ No
TRANSFER/SALE OF ASSETS
Have
you or the
other party
sold or
transferred ownership
of any
asset
in the last 12 months? ☐
Yes ☐ No
Have you or the other party
withdrawn
funds from an
account
in the last 12 months for a
purpose
other than
paying normal household expense
payments?
☐
Yes ☐ No
If you
answered
''Yes'' to either of the above
questions,
please list asset sold or
transferred
OR
account
from which withdrawal was
made, amounts received or withdrawn and any expenditure made from amounts received.
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YOU MUST COMPLETE THE REMAINING PAGES OF THIS FORM IF YOU ANSWERED ''YES'' TO ANY OF THE QUESTIONS ABOVE. IF
YOU ANSWERED ''NO'' TO ALL QUESTIONS ABOVE, YOU DO NOT HAVE TO COMPLETE THE REMAINING PAGES OF THIS FORM.