Form 4A-215. Separate property and liabilities schedule.

STATE OF NEW MEXICO COUNTY OF ___________________________ ____________________ JUDICIAL DISTRICT _______________________________________, Petitioner, v. No. _________________ _______________________________________, Respondent. SERVE THIS FORM ON THE OTHER PARTY. DO NOT FILE WITH THE COURT. SEPARATE PROPERTY AND DEBTS SCHEDULE ASSETS: Petitioner Respondent 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: $ _____________ $ _____________ DEBTS: a. _______________________ $ _____________ $ _____________ b. _______________________ $ _____________ $ _____________ c. _______________________ $ _____________ $ _____________ d. _______________________ $ _____________ $ _____________ Total Separate Debts: $ _____________ $ _____________ NET SEPARATE PROPERTY: $ _____________ $ _____________ I, _______________________, affirm under penalty of perjury under the laws of the State of New Mexico that I am the [ ] Petitioner (or) [ ] Respondent in the above-entitled cause, and I know and understand that the contents of this Schedule are true to the best of my knowledge and belief. ___________________________________________ Signature of party Date ___________________________________________ Name (print) ___________________________________________ Mailing address (print) ___________________________________________ City, state, and zip code (print) ___________________________________________ Telephone number