FINANCIAL INFORMATION AND INCOME STATEMENT
The financial information on the following pages is important. If you need help in completing any item, please let the Dispute Resolution Associate know.
Please bring this information to the mediation session, along with documentation for the items on the sheet (i.e., bank statement, appraisals, etc.). Please also bring or have available copies of Federal and State income Tax returns for the past three years and W-2 forms or copies of your pay stubs.
ASSETS
Enter the value of each of the following items of property as precisely as you can. Also identify the property as precisely as possible, including account numbers, names of banks, etc. List according to the name the property is titled under.
A. Real Estate (Residence, Vacation Home,and Investment):
Fair market value
Mortgage
$
$
$
B. Checking Accounts and Saving Accounts: List bank or financial institution and last 4 digits of account
number:
Bank Name:
Amount:
$
$
$
C.
Vehicles, Boats, Trailers (year, make
Fair market value
Loan amount owed today
$
$
$
D. Credit Union and Deposit Accounts
(Account name, number, bank and
Branch) :
Bank Name:
Amount:
$
$
$
E.
Cash (Give location):
$
$
$
F.
Tax Refund: tax year & amount, State or Federal debt
$
$
$
G.
Miscellaneous Assets – Patents
Fair market value
Debt owed
Trademarks, Copyrights, Royalties
Stock Options, etc.:
$
$
$
H.
H.
Stocks, Bonds, Secured Notes,
Mutual Funds: List financial institution & acct. number
Loan?
$
$
$
I.
Personal Effects, Antiques or Art, Tangible
Personal Property (valued at $500 or more):
$
$
$
J.
Pension plans, Keogh, IRAs or
Today’s Value
Loan Amt
Profit Sharing Plans, (Please
Furnish last statement):
$
$
$
K.
Accounts Receivable and Unsecured
Notes: (money others owe you)
Amount
$
$
$
L.
Partnerships and Other Business
Fair market value
Loans owed
Interests:
$
$
$
If you are involved in a lawsuit (either plaintiff or defendant) or have separate property claims (premarital assets, inheritances, gifts from your family), please let us know.
TOTAL ASSETS
LIABILITIES
A.
Student Loans: List debtor and acct #
Amount you owe today
$
B.
Personal Loans and Notes Payable to Banks and Others:
$
C.
Credit Card Debts: (list card name & number) Amount you owe today
$
D.
Other Debts (including store charges,
debts to other spouse or parents):
Amount you owe today
$
A.
Taxes owed: (give tax year and state or federal) Amount you owe today
$
TOTAL LIABILITIES
Security Code
