Free Asset and Debt Statement - Hawaii

STATE OF HAWAI`I
FAMILY COURT THIRD 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 REPROGRAPHICS (6/08)

ASSET AND DEBT STATEMENT 3F-P-272

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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 REPROGRAPHICS (6/08)

ASSET AND DEBT STATEMENT 3F-P-272

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 REPROGRAPHICS (6/08)

ASSET AND DEBT STATEMENT 3F-P-272