STATE OF HAWAI`I
FAMILY COURT FIRST CIRCUIT
CASE NUMBER
ASSET AND DEBT STATEMENT u Plaintiff u Defendant u Both Parties u
PLAINTIFF (Full Name)
Plaintiff
FC-D NO.
This document is prepared by
u
Defendant
u
Atty. for Plaintiff
u
Atty. for Defendant
_________________________________________________
Name
_________________________________________________ VS. _________________________________________________
Address
_________________________________________________ DEFENDANT (Full Name)
City, State, Zip
_________________________________________________
Phone
1. Cash (on hand or held by others for me) 2. CREDIT UNION ACCOUNTS:
Name Title (H,W,J)
$ ______________________________________
Credit Balance
Debt Balance
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
3. BANK AND SAVINGS ACCOUNTS:
Company & Branch
(Include Trustee Accounts)
Title (H,W,J) Current Balance
Type of Account
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
4. SECURITIES:
Company
(Stocks, Bonds, Mutual Funds, Certificates of Deposit, etc.)
Title (H,W,J) Date of Acquisition Cost Market Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063
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Page 2 5. VEHICLES:
Year
(Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.)
Make Title (H,W,J) Currrent Market Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
6. REAL PROPERTY:
Address Fee or Lease Tltle (H,W,J) Date of Acquisition Cost Current Gross Value Total Debt Owed
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
7. LIFE INSURANCE:
Company Person Insured Face Amount Beneficiary Title (H,W,J) Cash Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
8. RETIREMENT; PENSION; PROFIT SHARING ACCOUNTS:
Employer or Company Title (H,W,J) Type of Plan Years in Plan Total Value
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
9. ALL OTHER MAJOR ASSETS: (Furniture, Household Effects, Art, Stamps, Coins, Tools, Equipment, Jewelry, Accounts Receivable, Investment Assets, Business Assets, Cemetary Plots or Niches, Tax Refunds Due, etc.)
General Description Title (H,W,J) Estimated Gross Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063
Page 3 10. PROPERTY HELD IN TRUST FOR OR BY THIRD PERSON/S: (Aside from Bank & Savings Accounts Noted in paragraph 3)
Description Trustee/s Beneficiaries Value Debt Owed Against
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
11. ALL OUTSTANDING DEBTS: (Include those listed parts in 2, 4, 5, 6, 7, 9, and 10 above, in addition to all credit cards, charges, finance companies, and personal loans.)
Creditor Debtor (H,W,J or Other) Security Mo./Yr. Debt Incurred Total Balance Owed Minimum Monthly Payment
___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________
Total Debt in Wife's Name Alone: ______________________________________________________________________________ Total Debt in Husband's Name Alone:
_________________________________________________________________________
Total Debt in Joint Names: ______________________________________________________________________________________
CERTIFICATION I hereby declare under the penalty of perjury that I have supplied the information used in this Asset and Debt Statement and have reviewed this statement and I certify that the information is accurate, complete and correct.
DATE
u
PLAINTIFF'S u DEFENDANT'S SIGNATURE
DATE
u
PLAINTIFF'S u DEFENDANT'S SIGNATURE
Form No. 073925 R12/97
ASSET AND DEBT STATEMENT 1F-P-063