4A-132
STATE OF NEW MEXICO
COUNTY OF ___________________________
___________________ JUDICIAL DISTRICT

_________________________________,
Petitioner,

v.            

No. ________________

_________________________________,
Respondent.

[PETITIONER] [AND] [RESPONDENT]'S SEPARATE

PROPERTY AND LIABILITIES SCHEDULE


ASSETS:
                                 Husband        Wife
1.    Checking & Savings Accounts:
    a. __________Bk, Ck. #__________        $_________        $_________
    b. __________Bk, Sav. #_________        $_________        $_________
    c. __________CD # ____________        $_________        $_________
    d. __________Cr Un #___________        $_________        $_________

2.    Bonds/Stocks:
    a. ____________ Sh.___________        $_________        $_________
    b. ____________ Sh.___________        $_________        $_________

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

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

5.    Insurance policies:

    a.    Company ____________________
        Policy No. _________________
        Face amount $_______________
        Cash value $________________
        Loan balance $_______________        $_________    $_________

    b.    Company _____________________
        Policy No. __________________
        Face amount $________________
        Cash value $_________________
        Loan balance $_______________        $_________    $_________

6.    Real estate:
    a. _______________
    Present value $______________
    Mortgage ($/mo) $____________
    REC ($/mo) $_________________            $_________    $__________

    b. _______________
    Present value        $_________________
    Mortgage ($/mo)    $_________________
    REC ($/mo)        $_________________    $_________    $__________

7.    Vehicles:
    a. ________________                $__________    $___________
    Lien ($/mo)                        $__________    $___________

    b. ________________                $__________    $___________
    Lien ($/mo)                        $__________    $___________

8.    Business assets                    $__________    $___________

9.    Household furniture and goods            $____________    $___________

10.    Tax refunds                        $___________    $___________

11.    IRA/Keogh/Annuity                    $___________    $___________

12.    Retirement                        $___________    $___________

13.    Retirement                        $__________    $__________

14.    Other total assets                    $__________    $__________

Total Separate Assets:                    $__________    $__________

LIABILITIES:

    a. ________________________            $___________    $__________
    b. ________________________            $___________    $__________
    c. ________________________            $___________    $__________
    d. ________________________            $___________    $__________

Total Separate Liabilities:                    $___________    $__________

NET SEPARATE PROPERTY:                $___________    $__________

    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

NOTARY PUBLIC


    Signed and sworn to before me this _____ day of ___________________, ______.

                                ____________________________


My commission expires: ___________________________

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