Form Approved for Optional Use Judicial Council of California FL-142 [Rev. January 1, 2005] Code of Civil Procedure, §§ 2030(c), 2033.5 www.courts.ca.gov

SCHEDULE OF ASSETS AND DEBTS (Family Law) Page 1 of 4 INSTRUCTIONS List all your known community and separate assets or debts. Include assets even if they are in the possession of another person, including your spouse. If you contend an asset or debt is separate, put P (for Petitioner) or R (for Respondent) in the first column (separate property) to indicate to whom you contend it belongs. All values should be as of the date of signing the declaration unless you specify a different valuation date with the description. For additional space, use a continuation sheet numbered to show which item is being continued.

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NO.: ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF PETITIONER: RESPONDENT:

SCHEDULE OF ASSETS AND DEBTS Petitioner's Respondent's CASE NUMBER: FL-142THIS FORM SHOULD NOT BE FILED WITH THE COURT ITEM NO. ASSETS DESCRIPTION SEP. PROP DATE ACQUIRED CURRENT GROSS FAIR MARKET VALUE AMOUNT OF MONEY OWED OR ENCUMBRANCE 1. REAL ESTATE (Give street addresses and attach copies of deeds with legal descriptions and latest lender's statement.) $ $ 2. HOUSEHOLD FURNITURE, FURNISHINGS, APPLIANCES (Identify.) 3. JEWELRY, ANTIQUES, ART, COIN COLLECTIONS, etc. (Identify.) —— FL-142 [Rev. January 1, 2005]

SCHEDULE OF ASSETS AND DEBTS (Family Law) Page 2 of 4 ITEM NO. ASSETS DESCRIPTION SEP. PROP DATE ACQUIRED CURRENT GROSS FAIR MARKET VALUE AMOUNT OF MONEY OWED OR ENCUMBRANCE 4. VEHICLES, BOATS, TRAILERS (Describe and attach copy of title document.) $ $ 5. SAVINGS ACCOUNTS (Account name, account number, bank, and branch. Attach copy of latest statement.) 6. CHECKING ACCOUNTS (Account name and number, bank, and branch. Attach copy of latest statement.) 7. CREDIT UNION, OTHER DEPOSIT ACCOUNTS (Account name and number, bank, and branch. Attach copy of latest statement.) 8. CASH (Give location.) 9. TAX REFUND 10.

LIFE INSURANCE WITH CASH SURRENDER OR LOAN VALUE (Attach copy of declaration page for each policy.) ITEM NO. ASSETS DESCRIPTION SEP. PROP DATE ACQUIRED CURRENT GROSS FAIR MARKET VALUE AMOUNT OF MONEY OWED OR ENCUMBRANCE 11. STOCKS, BONDS, SECURED NOTES, MUTUAL FUNDS (Give certificate number and attach copy of the certificate or copy of latest statement.) $ $ 12. RETIREMENT AND PENSIONS (Attach copy of latest

summary plan documents and latest benefit statement.) 13. PROFIT - SHARING, ANNUITIES, IRAS, DEFERRED COMPENSATION (Attach copy of latest statement.) 14. ACCOUNTS RECEIVABLE AND UNSECURED NOTES (Attach copy of each.)15. PARTNERSHIPS AND OTHER BUSINESS INTERESTS (Attach copy of most current K-1 form and

Schedule C.) 16. OTHER ASSETS 17. TOTAL ASSETS FROM CONTINUATION SHEET 18. TOTAL ASSETS $ $ FL-142 [Rev. January 1, 2005]

SCHEDULE OF ASSETS AND DEBTS (Family Law) Page 3 of 4 (SIGNATURE OF DECLARANT) Date: (TYPE OR PRINT NAME) ITEM NO. DEBTS—SHOW TO WHOM OWED SEP. PROP TOTAL OWING DATE INCURRED 19. STUDENT LOANS (Give details.) $ 20. TAXES (Give details.) 21. SUPPORT ARREARAGES (Attach copies of orders and statements.) 22. LOANS—UNSECURED (Give bank name and loan number and attach copy of latest statement.) 23. CREDIT CARDS (Give creditor's name and address and the account number. Attach copy of latest statement.) 24. OTHER DEBTS (Specify.): 25. TOTAL DEBTS FROM CONTINUATION SHEET 26.

TOTAL DEBTS $ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (Specify number): pages are attached as continuation sheets.27. FL-142 [Rev. January 1, 2005]

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