FINANCIAL INFORMATION AND INCOME STATEMENT

Name:

Email Address:

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(what you could sell it for today)

$

$

$

Mortgage
(debt owed)

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 and model):

Fair market value (today's sale price)

$

$

$

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 Trademarks, Copyrights, Royalties Stock Options, etc.:

Fair market value


$

$

$

Debt owed


H. Life Insurance with Cash Surrender

Cash Value

Loan amt.

Death Benefit

H. Stocks, Bonds, Secured Notes,
Mutual Funds: List financial institution & acct. number

$

$

$

I. Personal Effects, Antiques or Art, Tangible
Personal Property (valued at $500 or more):

$

$

$

J.Pension plans, Keogh, IRAs or Profit Sharing Plans, (Please Furnish last statement):

Today's Value

$

$

$

Loan Amt

K.Accounts Receivable and Unsecured

Notes: (money others owe you)

Amount

$

$

$

 

L. Partnerships and Other Business Interests:

Fair market value

$

$

$

Loans owed

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