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4 / 5

Make

Model

Year

$

Make

Model

Year

$

Make

Model

Year

$

  • D.

    Stock and Bonds (provide description) $

  • E.

    Retirement/IRA: $

$

F. Other Property (list all jewelry, equipment, boats, watercrafts, etc.)

$ $

$

$

$

Balance $ $ $ $

  • B.

    Real Property Owned; Description/Location:

  • C.

    Automobile(s)

G. Bank Accounts Bank Name

Type of Account

Assets Asset

Describe if house, condominium, apartment, other:

A. Place of Residence

___

Rent

___

Own

Value

H. Cash:_________________ I. Other Assets (Identify)

VALUE $

ASSETS TOTAL VALUE

$

Other Information I think you should know:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_______________________________ _______________________________ _______________________________

By signing my name below, I swear, that all of the above information about my financial condition is current, accurate, and true. By signing below, I understand that a court official can verify any of the information for accuracy as required to determine my eligibility.

_____________________________________________ Defendant’s Signature

SUBSCRIBED and SWORN to before me, the undersigned authority, this

___

day of

________________

, 20

___

_________________________________________ Notary Public

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