FINANCIAL INFORMATION AND INCOME STATEMENT
Name:__________________________________________________________________
Agreed upon date of validation:____________________________________
If there is any question by either party as to the value of any property or the balance on any account, bring in the documentation to the mediator (i.e., bank statements, appraisals, ect.). It may also be necessary to bring copies of Federal and State Income Tax returns and W-2 forums or copies of your leave and earning statements.
Enter the value of the following items of property precisely as you can. Also, identify the property as precisely as possible, names of banks, ect. List according to the name in which the property is titled.
ASSETS
A.
| Bank Accounts & Saving | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
B.
| Notes, Accounts | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
C.
| Stocks, Bonds | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
D.
| Real Estate | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
E.
| Life Insurance | Husband | Wife | Join | Documentation Provided |
| $ | $ | $ | ||
F.
| Business or Professional Interests | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
G.
| Pension Plans | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
H.
| Misc Assists | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
I.
| Personal Effects, (Valued at $500 or more) | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
| TOTAL ASSETS | $ | $ | $ |
LIABILITIES
A.
| Mortgages or Real Estate | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
B.
| Notes Payable to Bank and Others | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
C.
| Loans or Insurance Policies | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
D.
| Other Debts | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
| TOTAL LIABILITIES | $ | $ | $ |
ADDITIONAL CONSIDERATIONS
A.
| Revisions to Life Insurance | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
B.
| Revisions to Wills | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
C.
| Responsibility for Attorney’s Fees | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
D.
| Tax Obligations and Expectancies | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||
E.
| Pets (Who will retain ownership) | Husband | Wife | Joint | Documentation Provided |
| $ | $ | $ | ||