Property Questionnaire REAL PROPERTY First Name: Last Name: Phone: Email: City: State: Zip: Primary Residence (Homestead) Address Description of improvements, if any Legal description (from deed) Date purchased: Who is on Title: Purchase price Current fair market value as of (date) (value) Mortgage company Mortgage account number (if any) Outstanding mortgage balance as of (date) (balance) Second lien Outstanding second lien balance as of (date) (balance) Monthly payments Current net equity in property as of (date) (balance) Choose One Award to HusbandAward to WifeSell Choose One AgreedProposed Other Real Property Interest Address Description of improvements, if any Legal description (from deed) Date purchased Purchase price Current fair market value as of (date) (value) Mortgage company Mortgage account number (if any) Outstanding mortgage balance as of (date) (balance) Second lien Outstanding second lien balance as of (date) (balance) Monthly payments Current net equity in property as of (date) (balance) Choose One Award to HusbandAward to WifeSell Choose One AgreedProposed MINERAL INTERESTS Name of mineral interest/lease/well Type of interest Legal description (from deed or division order) County of location Name of producer/operator Current Value as of (date) (balance) How Acquired When By Whom Choose One Award to HusbandAward to WifeSell Choose One AgreedProposed Name of mineral interest/lease/well Type of interest Legal description (from deed or division order) County of location Name of producer/operator Current Value as of (date) (balance) How Acquired When By Whom Choose One Award to HusbandAward to WifeSell Choose One AgreedProposed CASH AND ACCOUNTS WITH FINANCIAL INSTITUTIONS Cash on hand as of (date) (amount) Traveler's checks on hand as of (date) (amount) Money orders on hand as of (date) (amount) Name of financial institution Type of account Name account held in Account number Date account was opened Persons named on withdrawal cards Account balance as of: (date) (amount) Choose One Award to HusbandAward to WifeClose Choose One AgreedProposed Name of financial institution Type of account Name account held in Account number Date account was opened Persons named on withdrawal cards Account balance as of: (date) (amount) Choose One Award to HusbandAward to WifeClose Choose One AgreedProposed Name of financial institution Type of account Name account held in Account number Date account was opened Persons named on withdrawal cards Account balance as of: (date) (amount) Choose One Award to HusbandAward to WifeClose Choose One AgreedProposed Name of financial institution Type of account Name account held in Account number Date account was opened Persons named on withdrawal cards Account balance as of: (date) (amount) Choose One Award to HusbandAward to WifeClose Choose One AgreedProposed BROKERAGE/MUTUAL FUND ACCOUNTS (include accounts not previously disclosed herein) Name of brokerage firm/mutual fund Address of brokerage firm Name account held in Name of account (and names of subaccounts, if any) Account number (and numbers of subaccounts, if any) Total account value as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of brokerage firm/mutual fund Address of brokerage firm Name account held in Name of account (and names of subaccounts, if any) Account number (and numbers of subaccounts, if any) Total account value as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of brokerage firm/mutual fund Address of brokerage firm Name account held in Name of account (and names of subaccounts, if any) Account number (and numbers of subaccounts, if any) Total account value as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed STOCKS, BONDS, OPTIONS AND OTHER INVESTMENT INSTRUMENTS Name of security/investment Type of security/investment (common stock/preferred stock/bond, etc.) Type of security/investment (common stock/preferred stock/bond, etc.) Certificate numbers Name in which held In possession of Date of initial ownership Name of exchange on which listed Brokerage house Brokerage house account number Present location of certificate(s) Is the security pledged as collateral? YesNo If so, to whom or to what entity? Market value as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of security/investment Type of security/investment (common stock/preferred stock/bond, etc.) Type of security/investment (common stock/preferred stock/bond, etc.) Certificate numbers Name in which held In possession of Date of initial ownership Name of exchange on which listed Brokerage house Brokerage house account number Present location of certificate(s) Is the security pledged as collateral? YesNo If so, to whom or to what entity? Market value as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed RETIREMENT ACCOUNTS Retirement Accounts/SEP/401(k): Name of plan Financial institution Name account held in Account number Payee of survivor benefits Designated beneficiary Total account balance: Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of plan Financial institution Name account held in Account number Payee of survivor benefits Designated beneficiary Total account balance: Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of plan Financial institution Name account held in Account number Payee of survivor benefits Designated beneficiary Total account balance: Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Company Retirement Benefits: Defined Contribution Plans Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Payee of survivor benefits Description of other benefits Balance of account as of date of marriage: Is there a loan or offset against the plan? YesNo If so, how much? Date any such loan or withdrawal was made Total account balance as of: (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Payee of survivor benefits Description of other benefits Balance of account as of date of marriage: Is there a loan or offset against the plan? YesNo If so, how much? Date any such loan or withdrawal was made Total account balance as of: (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Defined Benefit Plans Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Description of other benefits Accrued benefit as of date of marriage Value of plan as of: (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Description of other benefits Accrued benefit as of date of marriage Value of plan as of: (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Uniformed Services Branch of service Name of service member Current Rank/Pay grade of service member Starting date of creditable service Status of service member ActiveReserveRetired Payee of survivor benefits Description of other benefits Monthly benefit payable Value of plan as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Branch of service Name of service member Current Rank/Pay grade of service member Starting date of creditable service Status of service member ActiveReserveRetired Payee of survivor benefits Description of other benefits Monthly benefit payable Value of plan as of: (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Other Retirement Accounts Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Payee of survivor benefits Description of other benefits Balance of account as of date of marriage Is there a loan or offset against the plan? YesNo If so, how much? Date any such loan or withdrawal was made Total account balance as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of plan Name, address, and phone number of plan administrator Name of employee Name of employer Starting date of creditable service/Beginning date of participation in plan Percentage employee is vested Designated beneficiary Payee of survivor benefits Description of other benefits Balance of account as of date of marriage Is there a loan or offset against the plan? YesNo If so, how much? Date any such loan or withdrawal was made Total account balance as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed EMPLOYEE-RELATED BENEFITS Stock Options and Restricted Stock Stock Options Name of company Date of option/grant Vesting schedule Number of options Are the options exercisable? YesNo Are the options registered? YesNo Current stock price Strike price Current net market value as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Restricted Stock Name of company Date of grant Restriction schedule Number of shares Are the stocks registered? YesNo Current stock price Current market value as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Bonuses Name of company Name or description of bonus Date of bonus expected to be paid Time period covered by bonus Anticipated amount of bonus Form of bonus to be paid Name of company Name or description of bonus Date of bonus expected to be paid Time period covered by bonus Anticipated amount of bonus Form of bonus to be paid OTHER EMPLOYEE-RELATED BENEFITS Name of company Name or description of benefit Date benefit is expected to be paid Time period covered by benefit Anticipated amount of benefit Form of benefit to be paid Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of company Name or description of benefit Date benefit is expected to be paid Time period covered by benefit Anticipated amount of benefit Form of benefit to be paid Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed LIFE INSURANCE AND ANNUITIES: Insurance Company Policy No. Type of policy Name of insured Name of owner Beneficiary Date of issue Face amount or death benefit Amount of premiums Due dates of premiums Is there a loan against this policy? YesNo If so, how much? Date any such loan or withdrawal was made Cash surrender value as of (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Insurance Company Policy No. Type of policy Name of insured Name of owner Beneficiary Date of issue Face amount or death benefit Amount of premiums Due dates of premiums Is there a loan against this policy? YesNo If so, how much? Date any such loan or withdrawal was made Cash surrender value as of (date) (value) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed CLOSELY HELD BUSINESS INTERESTS/CORPORATIONS/PARTNERSHIPS Name of business Type Date of initial ownership Name of owner Shares, units or percentage of ownership Estimated fair market value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of business Type Date of initial ownership Name of owner Shares, units or percentage of ownership Estimated fair market value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of business Type Date of initial ownership Name of owner Shares, units or percentage of ownership Estimated fair market value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed CONTENTS OF SAFE DEPOSIT BOX/HOME SAFE/STORAGE FACILITY: Name and location of facility Account/box number/unit number Names of persons with access to contents Terms and length of lease Items in safe-deposit box or storage unit Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and location of facility Account/box number/unit number Names of persons with access to contents Terms and length of lease Items in safe-deposit box or storage unit Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed MOTOR VEHICLES, BOATS, AIRPLANES, CYCLES, TRAILERS, RVs, ETC.: Description (year, make, and model) Vehicle identification no. Exact name on certificate of title In possession of Date purchased Purchase price Does vehicle have a loan against it? AgreedProposed If yes, state amount of loan Exact name of creditor Fair Market value Net equity Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description (year, make, and model) Vehicle identification no. Exact name on certificate of title In possession of Date purchased Purchase price Does vehicle have a loan against it? AgreedProposed If yes, state amount of loan Exact name of creditor Fair Market value Net equity Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description (year, make, and model) Vehicle identification no. Exact name on certificate of title In possession of Date purchased Purchase price Does vehicle have a loan against it? AgreedProposed If yes, state amount of loan Exact name of creditor Fair Market value Net equity Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description (year, make, and model) Vehicle identification no. Exact name on certificate of title In possession of Date purchased Purchase price Does vehicle have a loan against it? AgreedProposed If yes, state amount of loan Exact name of creditor Fair Market value Net equity Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed MISCELLANEOUS PERSONAL PROPERTY: HOUSEHOLD FURNITURE, FURNISHINGS & FIXTURES: Description Estimated value Award To Agreed or Proposed HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP CLOTHING, JEWELRY, AND ITEMS OF PERSONAL ADORNMENT: Description Estimated value Award To Agreed or Proposed HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP MISCELLANEOUS SPORTING GOODS AND FIREARMS: Description Estimated value Award To Agreed or Proposed HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP Please leave this field empty. Δ ELECTRONICS AND COMPUTERS, OFFICE EQUIPMENT AND FURNITURE: Description Estimated value Award To Agreed or Proposed HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP ANTIQUES, ARTWORKS AND COLLECTIONS: Description Estimated value Award To Agreed or Proposed HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP HW AP CLUB MEMBERSHIPS: Name of club Name membership held in Type Debt Current Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of club Name membership held in Type Debt Current Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name of club Name membership held in Type Debt Current Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed TRAVEL AWARDS/FREQUENT FLYER MILEAGE ACCOUNTS, ETC.: Exact name of airline/program Account number Current number of miles/points Name of owner Value of account Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of airline/program Account number Current number of miles/points Name of owner Value of account Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of airline/program Account number Current number of miles/points Name of owner Value of account Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of airline/program Account number Current number of miles/points Name of owner Value of account Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Exact name of airline/program Account number Current number of miles/points Name of owner Value of account Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed SPORTS AND CULTURAL TICKETS AND MEMBERSHIPS Type Cost Number of seats Debt Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Type Cost Number of seats Debt Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed LIVESTOCK/PETS: Description Value Choose One Award to HusbandAward to WifeSplit Visitation Schedule YN Choose One AgreedProposed Description Value Choose One Award to HusbandAward to WifeSplit Visitation Schedule YN Choose One AgreedProposed Description Value Choose One Award to HusbandAward to WifeSplit Visitation Schedule YN Choose One AgreedProposed Description Value Choose One Award to HusbandAward to WifeSplit Visitation Schedule YN Choose One AgreedProposed MONEY OWED TO EITHER HUSBAND OR WIFE Name of debtor Debtor's relationship to you Is debt evidenced in writing? YesNo Is debt secured? YesNo If so, with what is the debt secured? When was the money loaned? When is the debt due to be paid? How much was the original loan balance? Current loan amount owed as of (date) (amount) Name of debtor Debtor's relationship to you Is debt evidenced in writing? YesNo Is debt secured? YesNo If so, with what is the debt secured? When was the money loaned? When is the debt due to be paid? How much was the original loan balance? Current loan amount owed as of (date) (amount) Name of debtor Debtor's relationship to you Is debt evidenced in writing? YesNo Is debt secured? YesNo If so, with what is the debt secured? When was the money loaned? When is the debt due to be paid? How much was the original loan balance? Current loan amount owed as of (date) (amount) CONTINGENT ASSETS AND CLAIMS Description: Estimated Value Description: Estimated Value Description: Estimated Value ANY OTHER ASSETS Description Location Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description Location Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description Location Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Description Location Value Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Part 2 CLAIMS OF ECONOMIC CONTRIBUTION/REIMBURSEMENT BY ONE SPOUSE TO THE OTHER Estate with claim Estate against which claim is made Nature of claim Value Estate with claim Estate against which claim is made Nature of claim Value Estate with claim Estate against which claim is made Nature of claim Value Estate with claim Estate against which claim is made Nature of claim Value Part 3 UNSECURED COMMUNITY LIABILITIES CREDIT AND DEBIT CARDS AND CHARGE ACCOUNTS: Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Name and type of account Financial institution/issued by Account number Minimum monthly payment Name(s) on account Signatures on credit card application Name(s) of authorized users Balance transferred from (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed UNSECURED LOANS OWED TO OTHER PEOPLE: Loan payable to Loan made by Original loan amount Balance as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed Loan payable to Loan made by Original loan amount Balance as of (date) (balance) Choose One Award to HusbandAward to WifeSplit Choose One AgreedProposed FEDERAL, STATE AND LOCAL TAX LIABILITY: Entity owed Tax year WIFE Amount owed as of Entity owed Tax year HUSBAND Amount owed as of CONTINGENT LIABILITIES (e.g., lawsuits against either party, guaranty either party may have signed): Name of creditor Name of person primarily liable Guaranteed by Nature of contingency Amount of contingent liability WIFE HUSBAND OTHER LIABILITIES NOT PREVIOUSLY LISTED IN THIS INVENTORY Description Amount owed as of (date) (balance) Description Amount owed as of (date) (balance) Description Amount owed as of (date) (balance) Description Amount owed as of (date) (balance) Part 4 TRUST, ESTATE, AND CUSTODIAL ASSETS ASSETS HELD BY EITHER PARTY FOR THE BENEFIT OF ANOTHER Name of person holding assets Description of assets Name and title of fiduciary (e.g., executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) Name of person holding assets Description of assets Name and title of fiduciary (e.g., executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) Name of person holding assets Description of assets Name and title of fiduciary (e.g., executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) Name of person holding assets Description of assets Name and title of fiduciary (e.g., executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) ASSETS HELD BY ANOTHER FOR THE BENEFIT OF EITHER PARTY OR FOR THE CHILDREN Name of person holding assets Description of assets Name and title of fiduciary (e.g. executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) Name of person holding assets Description of assets Name and title of fiduciary (e.g. executor, trustee) Name of owner of beneficial interest Value of assets as of (date) (value) CUSTODIAL ACCOUNTS UNDER UNIFORM TRANSFERS TO MINORS ACT: Name of financial institution Type of account Name of account Account number Date account was opened Persons named on withdrawal cards Name of minor Account balance as of (date) (balance) Part 5 SEPARATE PROPERTY AND SEPARATE LIABILITIES SEPARATE PROPERTY AND LIABILITIES OF WIFE: Description When Acquired How Acquired Estimated Value SEPARATE PROPERTY AND LIABILITIES OF HUSBAND: Description When Acquired How Acquired Estimated Value Please leave this field empty. 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