Equitable Distribution Form {6}

Rule 30E (10/31/95) PART 1 MARITAL The (H) or (W) column is for the purpose of indicating preference in distribution between Husband and Wife PLAINTIFF DEFENDANT (H) (H) FMV Debt/lien FMV Debt/lien ITEM NO. OR ASSET OR DOS DOS DOS DOS (W) (W) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 1 <<<<<<<<<********>>>>>>>>>>>>> 2Rule 30E (10/31/95) PART II SEPARATE Item PRE - PRESENT ASSET GIFT INHT. FOR COURT USE ONLY No. DOM FMV 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 2 <<<<<<<<<********>>>>>>>>>>>>> 3Rule 30E (10/31/95) PART II MIXED EQUITY PLAINTIFF DEFENDANT Item FMV FMV ASSET DOM CONTRIBUTION CONTRIBUTION No. DOM DOS (H) / (W) POST DOM POST DOM 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 3 <<<<<<<<<********>>>>>>>>>>>>> 4Rule 30E (10/31/95) PART IV PENSION TOTAL NO. OF TOTAL NAME OF PENSION/ MONTHS IN AMT. PAID OR MONTHS OF VALUE AS OF DOS RETIREMENT PLAN PLAN AS OF TO BE PAID MARRIAGE DOS 4 <<<<<<<<<********>>>>>>>>>>>>> 5Rule 30E (10/31/95) PAR T V MARITAL DEBT *Current amount owed may be offered into evidence at trial AMOUNT ITEM IF SO, NAME AND OWED AT PURCHASED DEBT DESCRIBE FOR COURT USE ADDRESS OF DOS OR REASON SECURED? THE ONLY CREDITOR FOR DEBT PROPERTY * 5 <<<<<<<<<********>>>>>>>>>>>>> 6Rule 30E (10/31/95) PART VI INCOME AND EXPENSESSEPARATE GROSS INCOME STATEME NT Weekly Monthly Bi-Weekly Salary & Wages (Include bonuses, commissions, overtime and tips) Pensions and retirement Social Security Disability and Unemployment benefits Public Assistance (AFDC, food stamps, etc.) Rents Child support/ alimony payments Dividends and Interest income from all other sources (list each) TOTAL GROSS INCOME DEDUCTIONS FROM GROSS INCOME Federal income taxes Union or other dues State income taxes Retirement or pension fund Social Security Savings Medical insurance Other deductions TOTAL DEDUCTIONS AVERAGE MONTHLY EXPENSES Rent or mortgage Utilities & telephone Taxes and insurance Clothing & laundry Maintenance Medical & Dental Food and household Child care supplies Other TOTAL EXPENSE 6