SEPARATION AGREEMENT -

GENERAL INSTRUCTIONS, NOTES & FORM

Separation agreements are used by married couples that are living apart and contemplating a
divorce. A Separation Agreement establishes a contractual relationship between a husband and a
wife – the contract can cover issues relating to division of property, payment of debts, spousal
support (alimony), child support, and child custody if children are involved (since no children are
involved in your divorce/dissolution, there are no provisions concerning child support or child
custody in this document). After the Separation Agreement is signed (but before any legal
separation, dissolution or divorce proceeding in which the agreement is incorporated is
finalized), the Separation Agreement can be amended or modified if both parties agree to such
amendment or modification and if the amendment or modification is done in writing. A
Separation Agreement (as well as any amendments or modifications) needs to be signed by both
parties and notarized.

This Separation Agreement should not be confused with any document that may be
required to start divorce proceedings (i.e. a legal separation) – this document is merely a
contract for dividing property by and between the spouses. A divorce/legal separation
requires the filing of certain documents with the court whereby the parties specifically ask
for an end to a marriage. While a separation agreement is often used in or as part of a divorce
proceeding, this document alone is not intended (nor should it be used as) as the “court
document” to initiate a divorce. Standard Legal Network offers divorce software on its web site
that can be utilized for obtaining a divorce.

A Separation Agreement is intended to specifically provide the details of how the parties shall
treat various issues and how the marriage relationship shall terminate (if a divorce is
contemplated).

There are several steps that should be taken prior to the time the Husband and Wife prepare and
execute the Separation Agreement. These include: Conducting an inventory of all household and
family possessions and assets, determining how the assets of the family will be shared or divided
between the spouses, conducting an inventory to determine all of the family debt (as well as any
debt that my be the sole responsibility of Husband or Wife) and determining how such debt will
be paid and by whom it will be paid, determining if one spouse will or should pay monetary
support to the other and for how long, etc. The inventory items described above should be set
forth on the accompanying Financial Information Worksheet, and this Worksheet should be as

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accurate as possible and should contain all or substantially all of the assets and liabilities of the
Husband and Wife. The Worksheet should be prepared by each spouse and then a copy provided
to the other spouse.

At the time that the spouses enter into a Separation Agreement, the document is NOT to be filed
by itself with any court. However, when a divorce, dissolution or legal separation proceeding is
commenced, the executed Separation Agreement should be attached to the complaint or petition
that requests a court to grant a divorce (in New York, the Separation Agreement itself must also
be filed in the County in which one or both of the spouses live). The terms of the Separation
Agreement are generally incorporated into the final judicial order granting the divorce. When
the Separation Agreement is incorporated into the divorce order, the terms of the agreement
become an order of the court and are enforceable by the court.

Both the Husband and Wife must sign the Agreement in the presence of two witnesses (the two
witnesses can be the same for both sellers – but the husband should not witness the wife’s
signature or vice versa). The witnesses must both sign and print their names where indicated.
The legal description of any real property must be ACCURATELY inserted. The spouses must
also have the Agreement notarized – meaning that it must be signed in the presence of a notary
or they must testify to the notary that their true and accurate signatures appear on the deed. After
executing and notarizing the Agreement, each spouse should be provided with a copy of the
Agreement. If a divorce is ultimately filed, the Agreement should be included with any
complaint or petition for divorce, dissolution or legal separation that will be filed with the court.

NOTE: These instructions are not intended to provide tax advice to the parties to this Agreement.
A tax attorney, tax preparer, an accountant or other qualified individual should be consulted if
any questions arise regarding tax treatment of any issues arising out of this Agreement.

SEPARATION AGREEMENT - ADDITIONAL INSTRUCTIONS:

On the Financial Information form, simply insert the dollar values responsive to the question or
request, and, if requested, indicate which party to the marriage owns the property.

After the document is signed, initialed, witnessed and notarized, make several copies of the
same, provide one set to your spouse and distribute another set to your most trusted friend or
advisor. These copies can serve as "backup" versions should the original be lost or destroyed.
However, if the original document is lost or destroyed, making a new document may be an
appropriate measure to ensure that no problems are experienced later. Keep the original
document in a safe (and fireproof) place.

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INSTRUCTIONS FOR COMPLETING THE SEPARATION AGREEMENT:

Insert the appropriate information into each of the gray boxes below. Move to the next box by
hitting the “TAB” key. Instructions for each box are available in the lower left corner of your
computer screen or by hitting the F1 key on your keyboard, when you are “inside” a gray box.

[END OF INSTRUCTIONS]

© Standard Legal Network INSTRUCTIONS - PAGE 3

 SEPARATION AGREEMENT

This Separation Agreement is made by and between      , who lives at      , County
of      , State of      , hereinafter referred to as “Husband,” and      , who lives at      ,
County of      , State of      , hereinafter referred to as “Wife.”

This Agreement is effective      , although either or both parties may have signed it
before or after that date.

WHEREAS, each of the parties is more than 18 years of age, and they desire to confirm
their separation and to make arrangements in connection therewith, including the settlement and
adjustment of their property rights and other rights, responsibilities, and obligations growing out
of their marital relationship; and

WHEREAS, after careful consideration, each party believes it is in his or her own
respective best interests to enter into this Separation Agreement and Property Settlement and
each party considers this Agreement to be fair, reasonable and equitable; and

WHEREAS, each party has read this Agreement, fully understands the terms, conditions
and provisions hereof and deems such to be fair, just, and equitable;

NOW, THEREFORE, in consideration of the mutual promises and undertakings of the

parties herein contained and for other good and valuable consideration, the receipt of which is
hereby acknowledged, each party stipulates, agrees and covenants with the other as follows:

ARTICLE 1. Information about the parties.

A. The parties were married on      , at      .

B. Husband and Wife together do NOT have minor children under age 18, or under age 20
and still in high school, or adult dependents who are not able to support themselves because of a
physical or mental condition.

C. The wife in this marriage    is    is not now pregnant. If pregnant, the expected
date of birth of such child is:      

D. The Wife has minor children born prior to the marriage from another marriage or
relationship:    YES    NO (mark one box only).

If YES, the full name, date of birth, and age of each child is:

Full Name of Each Child Date of Birth Age Residence Address

                       
                       

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E. The Husband has minor children born prior to the marriage from another marriage or
relationship:
   YES    NO (mark one box only).

If YES, the full name, date of birth, and age of each child is:

Full Name of Each Child Date of Birth Age Residence Address

                       
                       
                       
                       
                       
                       
                       
                       

ARTICLE 2. Freedom of Action; Noninterference.

From and after the date of this Agreement, it shall be lawful for Husband and Wife to live
separate and apart, each from the other, as fully, completely and in the same manner and to the
same extent as though they had never been married. Each shall be free from interference, direct
or indirect, by the other as fully as though unmarried. Neither party shall molest or interfere with
the other. Each may, for his or her separate benefit, engage in any employment, business, or
profession that he or she may choose.

ARTICLE 3. Property and Property Division.

A. Real Estate. Husband and Wife jointly own real property:

   YES    NO (mark one box only). If YES:

The street address of the property is      , in the City of      , County of      , State of
      and it is legally described as follows:

     .

This real property was purchased on       for $     .

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There is a mortgage or loan against the property in the amount of $     .
The market value of the property is $     .
This property is the homestead of the parties:    YES    NO.
This parcel of property shall be treated as follows:

     

See Attachment for additional properties owned jointly:    YES (mark this “Yes” box if you
have an attachment for this category of property on which additional information is provided)

B. Husband owns real property solely in his own name or with someone other than Wife:
   YES    NO (mark one box only). If YES:

The street address of the property is      , in the City of      , County of      , State of
      and it is legally described as follows:

     .

This real property was purchased on       for $     .

There is a mortgage or loan against the property in the amount of $     .
The market value of the property is $     .
This property is the homestead of the parties:    YES    NO.
This parcel of property shall be treated as follows:

     

See Attachment for additional properties owned jointly:    YES (mark this “Yes” box if you
have an attachment for this category of property on which additional information is provided)

C. Wife owns real property solely in her own name or with someone other than Husband:
   YES    NO (mark one box only). If YES:

The street address of the property is      , in the City of      , County of      , State of
      and it is legally described as follows:

     .

This real property was purchased on       for $     .

There is a mortgage or loan against the property in the amount of $     .
The market value of the property is $     .
This property is the homestead of the parties:    YES    NO.
This parcel of property shall be treated as follows:

     

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See Attachment for additional properties owned jointly:    YES (mark this “Yes” box if you
have an attachment for this category of property on which additional information is provided)

D. Transfer of Marital Property from Husband to Wife. Husband transfers to Wife, as her
sole and separate property, all interest in the following marital property:

     .

E. Transfer of Marital Property from Wife to Husband. Wife transfers to Husband, as his
sole and separate property, all interest in the following marital property:

     .

F. Separate Property of Wife. It is agreed by the parties that the following is the separate
property of Wife, and Husband releases and assigns to her any claim that he may have in the
property:

     .

G. Separate Property of Husband. It is agreed by the parties that the following is the
separate property of the Husband, and Wife releases and assigns to him any claim that she may
have in the property:

     .

H. Payment of Debts by Husband. Husband agrees to pay all debts incurred by him after the
date of this Agreement and all of the following described debts incurred by the parties prior to
the date of this Agreement:

Debt Owed to Balance Owed Monthly Payment

      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     

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       $      $     
      $      $     

Husband further agrees that he will not contract any obligation for which his wife, or her
property or estate, may become liable and that he will save his wife harmless from future
liabilities he may incur.

I. Payment of Debts by Wife. Wife agrees to pay all debts incurred by her after the date of
this Agreement and all of the following described debts incurred by the parties prior to the date
of this Agreement:

Debt Owed to Balance Owed Monthly Payment

      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     
      $      $     

Wife further agrees that she will not contract any obligation for which her husband, or her
property or estate, may become liable and that he will save her husband harmless from future
liabilities he may incur.

J. The parties agree that the following property shall be sold at a reasonable fair market
value and the net proceeds of any sale, after payment of all reasonable sales expenses, including
brokers’ commissions, will be divided equally between husband and wife:

     

K. Disposition of Other Property. The parties have agreed that the following property shall be
disposed of in the following manner:

     

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 ARTICLE 4. Spousal Support

      agrees to pay to       for his/her support and maintenance, $      per month, beginning
      and on the first day of each month thereafter. Such payments shall continue until the first
to occur of the following events: (i) the death of the party receiving such support, (ii) the
remarriage of the party receiving such support, (iii) the death of party paying such support, (iv)
cohabitation of the party receiving such support with an unrelated adult or (v)      . In no
event and under no circumstances shall alimony payments extend beyond      , unless
terminated sooner by Husband's death, Wife's death or the remarriage of the party receiving such
support (marriage being defined herein as a church or civil marriage ceremony following the
issuance of a marriage license in the jurisdiction where performed), or cohabitation.

The parties further agree that there is no liability to make any of the foregoing alimony payments
for any period after the death of the party receiving such support and there is no liability to make
any payment (in cash or property) as a substitute for such payments after the death of the party
receiving such support. Any monthly payment that is not paid when due under this Agreement
shall bear interest, from the due date until paid, at the rate of 8% per year.       accepts the
payments specified in and to be made under this section in full satisfaction and settlement of all
his/her right, claim and demand against the other party hereto for support, maintenance and
alimony. The provisions for the support, maintenance and alimony of       are independent of
any division or agreement for division of property between the parties, and shall not for any
purpose be deemed to be a part of or merged in or integrated with the property settlement of the
parties.

ARTICLE 5. Income Tax.

The parties agree, in the event they are still married on December 31st of any year, to cooperate
in the filing of income returns, either jointly or as married filing separately and to file in the
manner which will result in the greater overall tax savings and benefit. In so doing, neither party
shall be required to pay more than he or she would have had to pay had he or she filed separately,
and shall be reimbursed by the other party for such refund he or she could have received. If the
savings exceeds the benefit to each, such excess refund (and only to the extent there is a refund)
shall be divided equally.

The parties agree to file separate tax returns for the year beginning      . Each party agrees to
hold the other harmless from any tax liability attributable to his income during that year. Each
party will be solely entitled to the credit for any prepayment made by him or her against his or
her own tax liability.

ARTICLE 6. Notices.

Except as herein otherwise expressly provided, any and all notices given hereunder or pursuant

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to the terms hereof, or on account hereof, shall be in writing and shall be sent by first-class mail
to either party at his or her residence address, and each party agrees to keep the other informed of
any change in his or her residence address.

ARTICLE 7. Partial Invalidity.

If any provision of this Agreement is held to be invalid or unenforceable, all other provisions
shall nevertheless continue in full force and effect.

ARTICLE 8. Warranty as to Financial Statements.

Each party has furnished to the other various financial statements and information reflecting the
parties’ financial condition as of      . Further, the parties agree that each has made a complete
disclosure of property and that neither knows of any property of any kind in which the party so
agreeing has any beneficial interest and the parties further agree and understand that they have
arrived at the settlement set forth in this Agreement on the basis of, and in light of, the
information set forth in such financial statements and disclosure. Each party represents and
warrants to the other that there have been no substantial changes in his/her financial
circumstances since the date set forth above and that such financial statements and disclosures
correctly, accurately, and fully reflect his/her financial condition as of the date upon which he
signed this Agreement.

In the event it is hereafter discovered that either party has failed to disclose, whether knowingly
or inadvertently, an asset the value of which is substantial (herein defined as having a value in
excess of $500.00) the other party shall be entitled to one-half if it is a divisible asset or 50% of
the value, as independently ascertained, of said asset.

ARTICLE 9. General

A. Waiver of Rights To Equitable Distribution and Other Rights in Marital Property.

Husband and Wife expressly acknowledge and agree that the division and distribution of marital
property set forth herein is just, fair and reasonable, is deemed by the parties to be equitable and
satisfactory, and that this Agreement shall be binding on the parties. Except as otherwise
provided herein, Husband and Wife further acknowledge that the foregoing provisions for the
division and distribution of property are made in full and complete satisfaction of any and all
claims specified hereinbelow. Each party expressly waives any and all claims, whether now in
existence or acquired hereafter, which either party may have against the other party or the
property of the other party under the present and future laws of this or any other jurisdiction
relating to the distribution of marital property, including, but not limited to, rights to division of
real and personal property, payment of capital sums or periodic payments, distributive shares,
pension or retirement benefits, life insurance and every other form of property, real or personal,
tangible or intangible, vested or contingent. Each party accepts the provisions of this Agreement
in lieu of and in full and final settlement and satisfaction of any and all claims and rights which

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either party may now or hereafter have against the other party for the distribution of property;
and the parties agree that this provision and this Agreement may be pleaded in bar of any such
claim for relief in any suit filed hereafter.

B. Mutual Release of Property Rights. Husband and Wife agree that each of said parties
may from this date and at all times hereafter purchase, acquire, own, hold, possess, encumber,
transfer, dispose of and convey any and all classes and kinds of property, real or personal,
tangible or intangible, or mixed, as though unmarried and free from the consent, joinder and
interference of the other party, it being the understanding and agreement on the part of each of
the parties hereto that in the sale, transfer and conveyance of any property hereafter it shall not
be necessary in order for the grantee to have a good title, that the other party hereto shall sign
and execute to the grantee the deed, conveyance, deed of trust, mortgage or bill of sale
conveying or selling the property; it being the agreement and covenant of the parties hereto that
in this respect, each of the parties hereto has forever released and discharged, and by these
presents each does hereby now forever release and discharge the property of the other from all
claims, interest and estate of his or her part, and that each shall be in the same position as if such
party were single and unmarried.

C. Sale of Property. In the event of a sale, transfer, or conveyance of any real or personal
property now owned or hereafter acquired by either of the parties, if (notwithstanding the mutual
releases contained in this Agreement) either party to this Agreement is called upon to execute a
deed, conveyance, bill of sale or other instrument conveying said property, then the party called
upon will sign any such instrument which may be reasonably required or reasonably necessary to
perfect title in the grantee of the property which is sought to be conveyed.

D. Mutual Release. Subject to the rights and privileges provided for in this Agreement and
in any deed or other instrument executed contemporaneously or in connection herewith, each
party does hereby release and discharge the other of and from all causes of action, claims, rights
or demands whatsoever, at law or in equity, which either of the parties ever had or now has
against the other, known or unknown, by reason of any matter, cause or thing up to the date of
the execution of this Agreement, except the cause of action for divorce based upon the separation
of the parties. It is the intention of the parties that henceforth there shall be, as between them,
only such rights and obligations as are specifically provided for in this Agreement, the right of
action for divorce, and such rights and obligations as are specifically provided for in any deed or
other instrument executed contemporaneously or in connection herewith, provided, however, that
the releases in this Agreement shall not apply to rights to any social security benefits the parties
may have by reason of their marriage to each other.

E. Waivers of Rights, Claims, or Benefits Relating to Wills, Trusts, Death Benefits, and
Insurance Proceeds for Property Damage. Husband and Wife expressly waive any right, claim or
benefit (including an appointment as personal representative, a bequest or devise) under any Will
executed by the other party prior to the date of this Agreement. Each party further waives,
releases, and renounces, and hereby conveys, quitclaims and assigns over to the other party and
his or her heirs, executors and administrators, any beneficial or administrative right arising under
any trust created by the other party prior to the date of this Agreement, any right to insurance
proceeds or employment benefits payable by reason of the death, disability or retirement of the

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other party except as set forth herein, and any right to insurance proceeds payable by reason of
damage or destruction to any real or personal property owned separately by the other party,
whether such property was distributed under this Agreement or acquired before or after the
execution of this Agreement by the other party. Husband and Wife further agree upon the death
of the other to execute such other and further documents including documents of renunciation as
may be reasonably required to give full force and effect to this agreement.

F. Effect Of Reconciliation. In the event of the reconciliation of the parties hereto, the
distribution of property under this Agreement shall remain in force, whether or not such
provisions are executed or executory. In the event any transfer of property to be made under this
Agreement has not been completed prior to any reconciliation, the transferor is not relieved of
his or her obligation to effectuate such transfer. Likewise, all obligations for the payment of
debts provided for herein shall remain in effect.

G. Transfers Of Property Incident To Divorce. The parties agree (i) that the transfer of
property hereunder is related to the divorce; (ii) that the transfer of property hereunder is a
transfer incident to divorce and is related to the cessation of the marriage; (iii) that the intent and
purpose of this Agreement is for the transfer of property hereunder to be tax free pursuant to
Section 1041 of the Internal Revenue Code and the applicable provisions of       law and for
no gain or loss to be recognized by either party as a result of such transfer; and (iv) that they will
file a formal election if necessary or otherwise take such actions as may be required by
applicable provisions of the state or federal income tax law and regulations to give full force and
effect to their aforesaid intent and purpose.

H. Additional Instruments. Each of the parties shall from time to time, at the request of the
other, execute, acknowledge, and deliver to the other party, any further instrument that may be
required to effectuate the terms of this Agreement.

I. Amendment. This Agreement can be altered and amended only by further written
agreement duly executed by the parties. Any failure by either party to specifically perform or to
enforce performance exactly according to the letter of this Agreement shall not constitute an
alteration of the same by way of enlargement, waiver, reduction, estoppel, or otherwise, unless
confirmed in writing by the parties. It is understood that the parties may, by mutual agreement,
make temporary modifications from time to time as conditions require, but this Agreement shall
nonetheless be binding upon the parties as written, except in the event of a material breach.

J. Jurisdiction. This Agreement, and the rights and duties of the parties hereunder, shall be
construed in accordance with, and governed by, the laws of the State of      .

K. Binding Effect. Except as otherwise stated herein, all the provisions of this Agreement
shall be binding upon the respective heirs, estates, next of kin, executors, administrators, and
assigns of the parties.

L. Entire Agreement. This Agreement, together with any exhibits and schedules attached
hereto, contains the entire understanding of the parties with respect to the subject matter; and
there are no representations, warranties, covenants or undertakings other than those expressly set

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forth herein. This Agreement supersedes and replaces all prior agreements and understandings
of the parties.

M. Voluntary Act. Each of the parties acknowledge that he or she has read this Agreement
and understands its contents and provisions; that it is a fair and reasonable agreement to each of
them, having due regard to the conditions and circumstances of the parties hereto on the date
hereof; that each has signed and executed the Agreement freely and voluntarily and without fear,
compulsion, duress, coercion, persuasion or undue influence exercised by either party upon the
other or by any other person or persons upon either.

THE PARTIES AGREE AND ACKNOWLEDGE THAT SHOULD A PROCEEDING OF

LEGAL SEPARATION, DISSOLUTION OR DIVORCE BE FILED IN ANY COURT OF
COMPETENT JURISDICTION, THIS AGREEMENT SHALL BE INCORPORATED INTO
ANY SUCH COMPLAINT OR PETITION FOR DIVORCE, DISSOLUTION OR LEGAL
SEPARATION, AND THEREAFTER BE INCORPORATED IN WHOLE IN ANY ORDER OR
JUDGMENT OF LEGAL SEPARATION, DISSOLUTION OR DIVORCE.

IN WITNESS WHEREOF, the parties have hereunto set their hands to four counterparts of this
Agreement, each of which shall constitute an original.

Witnesses for Wife: WIFE

________________________________ ___________________________________
Signature of Wife

________________________________

Witnesses for Husband: HUSBAND

________________________________ ___________________________________
Signature of Husband

________________________________

[ACKNOWLEDGEMENT ON FOLLOWING PAGE]

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ACKNOWLEDGEMENT

STATE OF ________________________ )
COUNTY OF _________________________)

Before me, a Notary in and for said County and State, _________________________________,
the Husband in the above Separation Agreement, who acknowledged that he did sign the
foregoing instrument and that the same is his free act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal, at _____________,
_________ this ____ day of _____________, 20___.

____________________________
Notary Public
My Commission Expires: ______________

ACKNOWLEDGEMENT

STATE OF ________________________ )
COUNTY OF _________________________)

Before me, a Notary in and for said County and State, _________________________________,
the Wife in the above Separation Agreement, who acknowledged that she did sign the foregoing
instrument and that the same is her free act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal, at _____________,
_________ this ____ day of _____________, 20___.

____________________________
Notary Public
My Commission Expires: ______________

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
[If you are a resident of California or New York, use the notary page below and do NOT use
the notary clauses on the page above. If you do not reside in California or New York, use the
notary clauses on the pages above and discard this page].

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
ACKNOWLEDGEMENT

State of _________________ )
County of ______________ )

On _______________ before me, ____________________________________________(here

insert name and title of the officer), personally appeared ________________________________,
who proved to me on the basis of satisfactory evidence to be the person whose name is
subscribed to the within instrument as HUSBAND and acknowledged to me that he executed the
same in his authorized capacity, and that by his signature on the instrument the person, or the
entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _______________ that
the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature __________________________________
(Seal)

****

State of _________________ )
County of ______________ )

On _______________ before me, ____________________________________________(here

insert name and title of the officer), personally appeared ________________________________,
who proved to me on the basis of satisfactory evidence to be the person whose name is
subscribed to the within instrument as WIFE and acknowledged to me that she executed the
same in her authorized capacity, and that by her signature on the instrument the person, or the
entity upon behalf of which the person acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _______________ that
the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature __________________________________
(Seal)

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
 FINANCIAL INFORMATION WORKSHEET
FOR:      

This form should be completed by each spouse - it should be filled in to the best of their
knowledge. Once finished, exchange the completed forms with the other spouse.

1. Gross Monthly Income (including wages, salary, alimony, rental income and all other
sources)

List Source Monthly

Amount
Source of Income:       $     
Source of Income:       $     
Source of Income:       $     
Source of Income:       $     

Total GROSS Monthly Income: $     

2. Deductions from Gross Monthly Income (insert the combined total amount of monthly
deductions from all sources listed above under Gross Monthly Income)

Federal Income Tax/withholding $     

State Income Tax/withholding $     
Local Income Tax/withholding $     

Social Security Tax/withholding $     

Self-employment Tax/withholding $     

Medicare/Medicaid/withholding $     
Health Insurance premiums (paid by you) $     
Pension/Retirement contributions $     

Union, Professional or Job Dues Paid $     

Child or Spousal Support Orders $     

Other Deductions from Income (describe):

      $     
      $     

Total Monthly Deductions: $     

3. Net Monthly Income (total monthly income minus total monthly deductions): $     

4. Monthly Expenses (List all expenses)

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
 Clothing Expenses:
New/Replacement $     
Alteration/repair $     
Laundry/Dry-cleaning $     
Other:       $     

Food Expenses:
Groceries $     
Other:       $     

Household Expenses:
Household supplies (non-food items) $     
Service (cleaning, pool, etc) $     

Yard Maintenance $     

Home Maintenance $     

Improvements $     
Furnishings (purchase and replacement) $     
Domestic Assistance (housekeeping) $     
Other:       $     
Other:       $     
Health/medical $     
Disability $     
Dental $     
Vision $     
Life $     
Homeowners/Renters $     
Property/casualty $     
Auto(s)/vehicles $     
Business insurance $     
Therapist/counselor $     
Other:       $     
Other:       $     

Medical expenses (not including insurance costs):

Medical $     
Dental $     
Vision/glasses $     
Prescriptions/drugs $     
Medical equipment/supplies $     
Other:       $     

Personal Expenses:
Work/business related $     
Tools/equipment $     

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
 Travel $     

Donations/gifts $     
Pet care $     
Hobbies $     
Dues/memberships $     
Banking Fees $     
Subscriptions $     

Hair care $     

Church/religious donations $     
Other:       $     
Other:       $     

Recurring debts/obligations:
Home loans/mortgage payments $     
Rent $     
Total vehicle payments $     
Student Loan $     
Other Loans:       $     
Other Loans:       $     
Other Loans:       $     
Other Loans:       $     
Other Loans:       $     
Other Loans:       $     
Credit Card - Acct #:       $     
Credit Card - Acct #:       $     
Credit Card - Acct #:       $     
Credit Card - Acct #:       $     
Credit Card - Acct #:       $     

Tuition Expenses:
Tuition $     
Books $     
Lunches $     
Extracurricular $     
Clothing/uniforms $     
Room/Board $     
Other:       $     
Other:       $     

Utility Expenses:
Electricity $     

Gas $     
Water & Sewer $     

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
 Garbage Collection $     
Telephone $     
Cellular Phone $     
Internet Service $     
Cable Television $     
Other:       $     
Other:       $     

Vehicle Expenses:
Fuel $     
Tolls/parking $     
Permits/licenses $     
Vehicle Maintenance/repair $     
Bus/Taxi/Subway $     
Other:       $     
Other:       $     

Other Expenses:
Other:       $     
Other:       $     
Other:       $     
Other:       $     
Other:       $     
Other:       $     

Total Monthly Expenses $     

5. Assets owned by you and/or jointly with spouse (List the current fair market value and
any amount that is owed on such asset – also, mark the line indicating which spouse owns the
property).
Amount Owned Owned Jointly
Property Owed by by Owned
Value Husband Wife
Residence $      $           
Vacation Home $      $           
Other real property $      $           
Motor Vehicles $      $           
Tools or equipment $      $           
Furniture/furnishings $      $           
Appliances $      $           
Art $      $           
Jewelry $      $           
Computer(s) $      $           
Other:       $      $           
Other:       $      $           

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
 TOTAL VALUE (Property Value minus Amount owed): $     

6. Cash-based assets owned by you and/or jointly with spouse. (List the total value or
equity in such assets.)

Assets Value Owned Owned Jointly

by by Wife Owned
Husband

Checking Account(s) $           

Savings Account(s) $           
Certificates of Deposit $           
Other deposits $           
IRA(s) $           
Pensions $           
Profit Sharing $           
Stocks/Bonds/Funds $           
Business(es) $           
Non-term life insurance $           

7. Any other assets not set forth above (Provide a description of the property, state its
value and list any amount owed on that asset).

Assets Value Amount Owned Owned Jointly

Owed by by Wife Owned
Husban
d

      $      $           

      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           
      $      $           

VALUE OF “OTHER ASSETS” $     

LISTED ABOVE

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
TOTAL OF ALL OF THE ASSETS LISTED ABOVE (in Paragraphs 5, 6 and 7): $     

_____________________________________
Signature of Party Preparing this Worksheet

Dated: __________________________

[ACKNOWLEDGEMENT ON FOLLOWING PAGE]

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
STATE OF ________________________ )

COUNTY OF _________________________)

Before me, a Notary in and for said County and State, _________________________, the Party
named above as the party preparing the Financial Information Worksheet, who acknowledged
that he/she did sign the foregoing instrument and that the same is his/her free act and deed.

IN TESTIMONY WHEREOF, I have hereunto set my hand and official seal, at _____________,
_________ this ____ day of _____________, 20___.

____________________________
Notary Public
My Commission Expires: ______________

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
[If you are a resident of California or New York, use the notary page below and do NOT use
the notary clauses on the page above. If you do not reside in California or New York, use the
notary clauses on the pages above and discard this page].

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____
ACKNOWLEDGEMENT

STATE OF _________________ )
COUNTY OF ______________ )

On _______________ before me, ____________________________________________(here

insert name and title of the officer), personally appeared ________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument as and acknowledged to me that he/she/they executed the
same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the
instrument the person(s), or the entity upon behalf of which the person(s)acted, executed the
instrument.

I certify under PENALTY OF PERJURY under the laws of the State of _____________ that the
foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature __________________________________
(Seal)

Initial:__________ © Standard Legal Network. All Rights Reserved. Page _____ of _____