§ Property and Debt Statement

Property and Debt Statement

    [Publisher's note: Referenced interactive forms can be accessed at www.selfrepresent.mo.gov]

    In what Missouri county was the                         In the Circuit Court of

    custody or support judgment entered?                                                                MISSOURI

    What is the case number of the custody or support
    judgment?
                                                                              Case Number                     Division Number

    Answer all questions on this form completely.

    Your Information             My current full name is:
                                          __________________     ______________      ________________     ___________

                                            (First Name)              (Middle Name)             (Last Name)        (Jr./Sr./III)

                                        [ ] I filed the original case. (Petitioner/Plaintiff)

                                        [ ] I did not file the original case. (Respondent/Defendant)

                                        [ ] I am the Mother

                                         [ ] I am the Father

 Other Party's
Information
                               The current full name of the other party is:
                                __________________         ______________     ________________     ___________
                                    (First Name)                     (Middle Name)            (Last Name)           (Jr./Sr./III)

Property Owned by

You                      Item of Property            Present Fair                           Monthl         Amount Owed on
Property?
                                                                Market Value (DoIncome              from         Property?
                                                                  Property
                                                                 not deduct amount                                    (List Debt in Table 2)

                                                                   owed from this
                                                                       value)



                                 Property is anything you own or you are in the process of buying. Anything you consider yours is
                                 property that should be listed. This includes anything that you might own with another person.

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                                                                                       [ ] Yes

                                                                                                                                       [ ] No

                                                                Property and Debt Statement--Page 1 of 3

    Form CAFC140-7/1/                      This form is available for free at www.selfrepresent.mo.gov
   2010

    Property Owned by
    You                               Item of Property           Present Fair                      Monthly          Amount Owed on
                                                                        Market Value (DoIncome    from              Property?
                                                                        not deduct amount
                                                                          owed from this                                    (List Debt in Table 2)
                                                                             value)

                                                                                                                                         [ ] Yes

                                                                                                                                         [ ] No

                                                                                                                                         [ ] Yes

                                                                                                                                         [ ] No

                                                                                                                                         [ ] Yes

                                                                                                                                         [ ] No


                                                                                                                                         [ ] Yes

                                                                                                                                         [ ] No

                                                                                                                                                                                                                                                                                   [ ] Yes

                                                                                                                                         [ ] No

                                                                                                                                         [ ] Yes

                                                                                                                                         [ ] No

    Debts Owed by You    Creditor    Current     Monthly                     Security for Loan
                                                   Balance    Payment on          (This property should be
                                                                     Loan                       listed in Table 1)


                                                 A debt is anything that you owe or that someone claims you owe.

                                         Property and Debt Statement--Page 2 of 3

Form CAFC140-7/1/          This form is available for free at www.selfrepresent.mo.gov
2010

    I certify under oath that I have given the other party a copy of this Property and Debt Statement pursuant to Missouri Supreme Court Rule 43.01(d) by: (You MUST check at least ONE of the following four boxes)

    [ ] Mailing a copy to the other party or his or her attorney on __________(Date) at the following address:

     _________________________________________________________________________
     (Street)

    _____________________________   _____________    _____________________________
                 (City)                                    (State)                              (Zip)

    [ ] Handing a copy to the other party or his or her attorney on __________ (Date).

    [ ] Sending a copy to the other party or his or her attorney by fax to __________(fax number) on __________(Date) at
__________(Time).

    [ ] (To be used only by written consent of the party filed with the court) Sending a copy via electronic mail to the other
party or his or her attorney at __________(Email Address) on __________(Date).

    Instructions: The following information MUST be filled in before a notary public. This Property and Debt Statement is
required to be verified before a notary public. The “Affiant” is the person that is completing this document.

    COUNTY OF
    _________________________________
                                                                       )

                                                                       ) ss.

      STATE OF _________________________________ )

    Affiant, of lawful age, being duly sworn on his or her oath, states that he or she is the affiant named herein and that the facts stated in this Property and Debt Statement are true according to his or her best knowledge and belief.

    _____________________________________________          ___________________________
Affiant--SIGN HERE (Sign here in front of a Notary Public)             Affiant--PRINT YOUR NAME HERE

    Subscribed and sworn to on

    _________________________________________________.

    _________________________________________________

    Notary Public

    My Commission Expires:

    _________________________________________________

                                                  Property and Debt Statement--Page 3 of 3

Form CAFC140-7/1/              This form is available for free at www.selfrepresent.mo.gov
2010

     [Publisher's note: Referenced interactive forms can be accessed at www.selfrepresent.mo.gov]