IN THE CIRCUIT COURT OF LAFAYETTE COUNTY, MISSOURI



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STATEMENT OF ASSETS AND DEBTS

OF PETITIONER/RESPONDENT

| |Present Fair |Amount |Equity |

| |Market Value |owed | |

|A. REAL ESTATE: List value of all real estate | | | |

|B. MOTOR VEHICLES: List value of all autos, boats, trailers, | | | |

|aircraft, recreational vehicles and campers and vehicle leases. | | | |

|C. BANK ACCOUNTS: List total amount in all checking, savings and money| | | |

|market accounts, certificates of deposit, held in your name alone or | | | |

|with another person. | | | |

|D. SECURITIES: List total value of all stocks, bonds, promissory | | | |

|notes, mortgages, etc. | | | |

|E. LIFE INSURANCE: List total cash value. | | | |

|F. RETIREMENT, PENSION, PROFIT SHARING: List name of the company and | | | |

|the present vested value of all plans. | | | |

|G. DEBTS OWED TO YOU BY OTHERS: List total debt amount. | | | |

|H. INTEREST IN SOLE PROPRIETORSHIP, | | | |

|PARTNERSHIPS, OR JOINT VENTURES: List total value. | | | |

|I. INTEREST IN PENDING LITIGATION OR SUIT NOT YET FILED: List total | | | |

|value. | | | |

|J. CASH ON HAND: | | | |

|K. HOUSEHOLD GOODS & PERSONAL GOODS: List the total value of all. | | | |

|L. OTHER ASSETS: List the total value of all assets not already | | | |

|listed herein, i.e., trusts. | | | |

DEBTS:

|List all loans from any bank, credit union, savings and loan association or other lending institution. Indicate who signed the loan, the |

|date of the loan, purpose of the loan, actual disposition of the proceeds and state the name and address of the lender. Also, list all |

|credit card balances and store charges. State whose name is on the credit card. Also list all other indebtedness and give the name and |

|address of the creditor. |

| DESCRIPTION: |CURRENT BALANCE |SECURED |REQUIRED MONTHLY |

| | |YES/NO |PAYMENT |

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AFFIDAVIT

I certify that I have read the above Statement of Assets and Debts and the facts therein are complete, true and accurate to the best of my knowledge and belief.

AFFIANT, ----------------------

Subscribed and sworn to before me, the undersigned, a Notary Public on this______ day of ____________________, 2010.

Notary Public

My Commission Expires:

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