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FINANCIAL AFFIDAVIT (400-813B) Property and Assets (Vermont Judiciary)

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400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 1 of 7
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Name
DOB
V.
Defendant Name
DOB
FINANCIAL AFFIDAVIT
(400-813B)
Property and
Assets
I am: ☐ Plaintiff ☐ Defendant ☐ Other: _____________________
Name
Mailing Address (if different from Street Address)
Town/City State Zip
Phone Number (evening)
Email Address
INSTRUCTIONS: You
are
required
to
complete and
file the
813B
if-
1.
You are
a
party
in a
newly filed divorce, civil union dissolution, legal separation
or
annulment and you and
the
other
party have minor children;
OR
2.
You are ordered by the Court
to
complete and file this form
or
the other party requests that you fill out the
form
as part
of the discovery
process.
DEADLINE FOR FILING: This form must
be
filed with
the
court before
or at
your first case manager's conference.
If
no conference
is
scheduled
it
must be filed
at
least seven (7) days before your first scheduled court
hearing.
YOU
MUST SEND
A
COPY
OF
YOUR COMPLETED FORM
TO THE
OTHER PARTY
AT THE
SAME
TIME YOU FILE IT
WITH
THE COURT.
When you have completed the form and filled
in
all the required information, you must sign the Affirmation section below and have your
signature
notarized.
AFFIRMATION
I have read and filled in all the
information
requested.
I
hereby affirm of my own knowledge that the facts and financial information
I
have stated are true and correct as of
the
date of this
Affirmation and that
I
am not omitting any source or amount of income or other information requested
on
this form.
I
understand that
any false information may constitute perjury by me.
I
also understand that
if I
fail
to
provide the required information or give
misinformation, the judge may order sanctions against
me.
_____________________________________________________________
Sworn
to
me
on
__________
__________________________________
My Commission Expires: ___________
Signature of Person Making A
ffidavit
Signature of Notary Public
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.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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.
400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 3 of 7
SECTION I - REAL
ESTATE
Description of Property
Including
Location
Market
Value
Mortgages,
Liens,
Attachments
Equity
(value minus liens)
Primary
Residence:
Second Home:
Camp:
Timeshare:
Unimproved
Land:
Mobile Home:
Residential Rental Real Estate
Owned:
Commercial Real
Estate:
Other Real Estate
Interests:
a.
b.
c.
d.
e.
TOTAL VALUE OF REAL
ESTATE
INTERESTS
IF ANY OF THE ABOVE PROPERTIES GENERATE RENTAL INCOME, YOU MUST
EITHER:
1. ATTACH SCHEDULE E FROM YOUR LAST 2 TAX
RETURNS
or if you did not file
taxes
2. FILL OUT RENTAL INCOME ATTACHMENT (See 400-00813A)
400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 4 of 7
SECTION II -
PERSONAL PROPERTY
List all personal property owned by you and/or the other party. In estimating the market
value,
please use the amount
you could reasonably receive if you sold the item today. Do not use the purchase price
or
replacement
value.
Description of
Items
Market
Value
Check if I
tem
is
in Your
Possession
Loans/Debts
on
Property
Person P
aying
on
Loan/Debt
Jewelry
Antiques
Artwork
Guns
Coins/Stamps
Tools
Collectibles
Piano/Musical instruments
China/Crystal/Silverware
Appliances
Electronics
Furnishings
Computers
Other:
a.
b.
c.
400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 5 of 7
SECTION III - VEHICLES and
BOATS
“Market value” for motor vehicles is the retail value indicated in the NADA Blue Book or other similar price guide.
Title
Holder
Vehicle
Description
(Year, Make, Model)
Market
Value
Outstanding
Loan
Amount
Equity
(Value minus Loan)
Car
#1
Car
#2
Truck
#1
Truck
#2
Motorcycle #1
Motorcycle #2
Boat #1
Boat #2
Snowmobile #1
Snowmobile #2
ATV #1
ATV #2
Camper
RV
Plane
Other
Vehicles:
a.
b.
SECTION IV - BUSINESS
OWNERSHIP
Owner
Name of Business, Type of Business Activity
and
Legal
Structure of Business (e.g. Sole
proprietor,
Partnership,
Corporation,
S-
Corporation)
% of
Interest
Owned
Date
of L
ast
Valuation
Fair
Market
Value
You Must Attach f o r m 400-00813A Self Employment Attachment or a Schedule C and/or Form K-1 from your last
two
(2) federal income tax returns for any business from which you earn or receive income, profits,
distributions,
in-kind
income,
etc.
400-00813B - Financial Affidavit – Property & Asset (01/2018) Page 6 of 7
SECTION V -
INVESTMENTS
Owner
Type of
Investment
(Stocks, B onds, Annuities, Mutual
Funds,
Trusts,
etc.)
Description
(Name of Company, F und, Bank, Trust and
Trustee
etc.)
Number
of
Shares
Market
Value
SECTION VI - BANK ACCOUNTS and
CASH
Owner
TYPE OF
ACCOUNT
Bank
Current
Balance
Checking Account
#1
Checking Account
#2
Savings Account #1
Savings Account #2
Money Market Account
#1
Money Market Account
#2
Cash in your
possession
Tax Exempt College Funds
or
Other College Savings
accounts
Health Savings
Accounts
Other
Accounts
SECTION VII - ACCOUNTS/FUNDS HELD FOR YOUR OR THE OTHER PARTY'S
BENEFIT
Trustee
or
Holder
Name of
Beneficiary
Type of
Account
Current
Value
400-00813B - Financial Affidavit – Property & Asset (01/2018)
Page 7 of 7
SECTION VIII - LIFE
INSURANCE POLICIES
Name Of
Insured
Beneficiary
Company
Face Value
Loan
Balance
Cash
Value
SECTION IX -
RETIREMENT ACCOUNTS
Owner
TYPE OF ACCOUNT
Financial
Institution
Value
IRA #1
IRA #2
401(k)
#1
401(k)
#2
403(b)
TIAA/CREF
Keogh
TDSP
TSA
Profit
Sharing
Savings &
Security
Program
Deferred Compensation
Other
Other
SECTION X -
PENSIONS
Owner
TYPE OF
PENSION
Pension
Administrator
Value
Defined Benefit
Defined
Contribution
Target
Benefit
Military
Pension
SEP
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FINANCIAL AFFIDAVIT (400-813B) Property and Assets (Vermont Judiciary)

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Completed 30 July 2020

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