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 following motor vehicles:

    1. Year, model and license number:

2. 2. Lienholder and amount of lien:

2. 3. Estimated value:

14. I own the following items of personal property each of which is valued at $500.00 or more and the estimated market value of each such item is:

    a.

    b.

    c.

    d.

    e.

15. I own shares of stock which have the following market value(s):

    a.

    b.

    c.

    d.

16. I have worth of bonds which have the following value(s):

    a.

    b.

    c.

    d.

17. I have a retirement account with , and this account has a value of $ . It is comprised of the following:

    a.

    b.

    c.

18. Other assets which I own which are not described above and have a value of over $500.00 per asset are the following assets with the following values:

    a.

    b.

    c.

    d.

19. My last financial statement was prepared for in and indicates a net worth of $ .

20. My total liabilities are $ and my total assets are $______.

    SUBSCRIBED AND SWORN to before me this day of , ___.

    ________________________

    NOTARY PUBLIC

    My Commission Expires:

    _______________________