Free 2C-E-167AssetDebt - Hawaii

STATE OF HAWAI`I
FAMILY COURT SECOND CIRCUIT

CASE NUMBER

ASSET AND DEBT STATEMENT Plaintiff Defendant Both Parties
Plaintiff

FC-D NO.

This document is prepared by



Defendant



Atty. for Plaintiff



Atty. for Defendant

PLAINTIFF (Full Name) VS.

_________________________________________________
Name

_________________________________________________ _________________________________________________
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)
Type of Account Title (H,W,J) Current Balance

_______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________

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 Reprographics (10/08)

ASSET AND DEBT STATEMENT 2C-E-167

Page 2 5. VEHICLES: (Autos, Trucks, Motorcycles, Trailers, Campers, Boats, etc.)
Year 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 Reprographics (10/08) ASSET AND DEBT STATEMENT 2C-E-167

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 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



PLAINTIFF'S DEFENDANT'S SIGNATURE

DATE



PLAINTIFF'S DEFENDANT'S SIGNATURE

Form No. 073925 R12/97 Reprographics (10/08)

ASSET AND DEBT STATEMENT 2C-E-167

CLEAR FORM