Affidavit for Determining Assets

Plaintiff )

vs. )

Defendant )

Comes now, defendant, after being first duly sworn upon his oath, and states that:

1. My full name is:

2. My home address is:

3. My social security number is:

4. My date of birth is:

5. My educational background since high school is:

6. My occupation is:

7. My work address is:

8. My present salary is: $ per year.

9. My income listed on my tax return for the last three years is:

   20:

   20:

   20:

10. I have the following savings account(s):

    1. Name of bank(s) and address of bank(s):

2. 2. Account number(s):

2. 3. Present balance(s):

   1 .

2. 4. Balance on date of accident:

11. I have the following checking account(s):

    1. Name of bank(s) and address of bank(s):

    1 .

2. 2. Account number(s):

2. 3. Present balance(s):

   1 .

2. 4. Balance on date of accident:

2. I own the following real estate:

   1. Address:

2. 2. Name of each bank or individual holding mortgage, real estate contract, or any other security interest against property and amount of each such security interest:

1. a.

   b.

   c.

2. a.

   b.

   c.

   3. Amount of equity in the property:

2. 4. Estimated market value:

2. 5. Other individual(s) who holds title with me.

13. I am the registered owner of the...