_________________________________________,
Petitioner,

v.            

_________________________________________,
Respondent.

    Neither party is required to submit a proposed distribution. Any stipulation regarding value or distribution should be indicated by an asterisk.

ASSETS              Value
                     Husband    Wife    Combined

1.    Cash            $_________    $_________    $_________

2.    Financial institution accounts: 1
    a.    __________    Account # _________    $_________    $_________    $_________
    b.    __________    Account # _________    $_________    $_________    $_________
    c.    __________    Account # _________    $_________    $_________    $_________
    d.    __________    Account # _________    $_________    $_________    $_________

3.    Stocks, bonds and mutual funds:
    a. ____________ Sh.___________    $_________    $_________    $_________
    b. ____________ Sh.___________    $_________    $_________    $_________
    c. ____________ Sh.___________    $_________    $_________    $_________

4.    Insurance policies:
    a.    Company _________________
        [Face amount $____________]
        Cash value        $___________    $_________    $_________
        Loan balance $ __________    $___________    $_________    $_________

    b.    Company _______________
        [Face amount $_________]
        Cash value        $___________    $_________    $_________
        Loan balance $ __________    $___________    $_________    $_________

5.    Real estate:
    a.    ___________    $________
    Mortgage ($/mo)    $________
    REC ($/mo)    $________
    Cost of sale
         ($/%)    $________    $________    $__________    $________

    b.    ___________    $________
    Mortgage ($/mo)    $________
    REC ($/mo)    $________
    Cost of sale
         ($/%)    $________    $________    $_________    $________

6.    Vehicles:
    a.    ___________    $________
    Lien ($/mo)    $________    $________    $_________    $________

    b.    ___________    $________
    Lien ($/mo)    $________    $________    $_________    $________

7.    Business assets        $________    $_________    $________

8.    Household furniture and
        goods            $________    $_________    $________

9.    Tax refunds        $________    $________    $________

10.    IRA/Keogh/Annuity    $________    $_________    $________

11.    Retirement        $________    $_________    $________

12.    Retirement        $________    $_________    $________

13.    Other total assets        $________    $_________    $________

Total assets            $_________    $_________    $________

LIABILITIES     (Mo/Pmt)    Value:    Husband:     Wife:

1.    ____________    $(_____)    $________    $________    $________

2.    ____________    $(_____)    $________    $________    $________

3.    ____________    $(_____)    $________    $________    $________

4.    ____________    $(_____)    $________    $________    $________

5.    Tax Liability    $(_____)    $________    $________    $________

Total liabilities:    $(_____)    $________    $________    $________

ESTIMATED
NET ASSETS:        $________    $________    $________

Equalization of
Assets:            $________    $________    $________

EQUAL ASSETS:        $________    $________    $________

    I have read the foregoing and the amounts are true and correct. I understand that if I make a material misstatement of fact, I may be prosecuted and punished for perjury.

                 ________________________________________
                Signature

                ________________________________________
                Name (print)

                ________________________________________
                Address (print)

                ________________________________________
                City, state and zip code (print)

                ________________________________________
                Telephone number

                    ____________________________

My commission expires: ____________________________.

    1.    Include all checking, savings and money market accounts and certificates of deposit.

[Approved, effective November 1, 2000 until November 1, 2001; approved, effective November 1, 2001.]