Split Simple, LLC Financial Questionnaire
Mediation Privileged and Confidential.
Your Full Name
Your answer
REAL ESTATE INTERESTS
Address of Primary Residence, if owned
Include street address, city and state.
Your answer
How is real estate titled?
Estimated Gross Market Value of Primary Residence
please do not include estimated closing costs and commissions
Your answer
Name of Mortgage Company / Bank First Mortgage (Primary Residence)
Your answer
In whose name is the first mortgage listed?
Outstanding Balance of First Mortgage (Primary Residence)
Your answer
Name of Mortgage Company / Bank Second Mortgage (Primary Residence)
Your answer
In whose name is the second mortgage listed?
Outstanding Balance of Second Mortgage (Primary Residence)
Your answer
Future of Real Estate
Please provide a description of how you would like to move forward with the Primary Residence.
Address of Other Real Estate
include rental properties and timeshares
Your answer
How is real estate titled?
Estimated Gross Market Value of Other Real Estate
please do not include estimated closing costs and commissions
Your answer
Name of Mortgage Company / Bank First Mortgage (other real estate)
Your answer
In whose name is the first mortgage listed?
Outstanding Balance of First Mortgage (other real estate)
Your answer
Name of Mortgage Company / Bank Second Mortgage (other real estate)
Your answer
In whose name is the second mortgage listed?
Outstanding Balance of Second Mortgage (other real estate)
Your answer
Future of Other Real Estate
Please provide a description of how you would like to move forward with the Other Real Estate.
If you own other real estate, please provide a brief description
include address, estimated gross market value, associated debt, how titled and proposed future
Your answer
If you own other real estate, please provide a brief description
include address, estimated gross market value, associated debt, how titled and proposed future
Your answer
MOTOR VEHICLES
You may consider researching the value of the motor vehicles on www.kbb.com, although we will typically review this information briefly during your mediation session. Clients ordinarily use "private party value" to determine the motor vehicle value.
Year, Make and Model of Motor Vehicle 1 Primarily Driven By Husband
Your answer
Estimated Private Party Market Value of Motor Vehicle 1 Primarily Driven By Husband
Your answer
Name of Bank / Lienholder on Vehicle 1 Primarily Driven by Husband
include lender name
Your answer
How is loan titled (husband, wife, joint)?
Outstanding Balance on Loan for Vehicle 1 Primarily Driven by Husband
Your answer
Year, Make and Model of Motor Vehicle 2 Primarily Driven By Husband
Your answer
Estimated Private Party Market Value of Motor Vehicle 2 Primarily Driven By Husband
Your answer
Name of Bank / Lienholder on Vehicle 2 Primarily Driven by Husband
include lender name
Your answer
How is loan titled (husband, wife, joint)?
Outstanding Balance on Loan for Vehicle 2 Primarily Driven by Husband
Your answer
Year, Make and Model of Motor Vehicle 1 Primarily Driven by Wife
Your answer
Estimated Private Party Market Value of Motor Vehicle 1 Primarily Driven By Wife
Your answer
Name of Bank / Lienholder on Vehicle 1 Primarily Driven by Wife
include lender name
Your answer
How is loan titled (husband, wife, joint)?
Outstanding Balance on Loan for Vehicle 1 Primarily Driven by Wife
Your answer
Year, Make and Model of Motor Vehicle 2 Primarily Driven by Wife
Your answer
Estimated Private Party Market Value of Motor Vehicle 2 Primarily Driven By Wife
Your answer
Name of Bank / Lienholder on Vehicle 2 Primarily Driven by Wife
include lender name
Your answer
How is loan titled (husband, wife, joint)?
Outstanding Balance on Loan for Vehicle 2 Primarily Driven by Wife
Your answer
Additional Motor Vehicles, Boats, RV's, Motorcycles, etc.
include those driven by children, estimated value and associated debt information
Your answer
Additional Motor Vehicles, Boats, RV's, Motorcycles, etc.
include those driven by children, estimated value and associated debt information
Your answer
BANK ACCOUNTS
Checking Account Titled in Joint Names
Please list institution and last four digits of account number.
Your answer
Range of Account Value During One Month Period
Your answer
Savings Account Titled in Joint Names
Please list institution and last four digits of account number.
Your answer
Range of Account Value During One Month Period
Your answer
Other Checking / Savings Account Titled in Joint Names
Please list institution and last four digits of account number.
Your answer
Range of Account Value During One Month Period
Your answer
Other Checking / Savings Account Titled in Joint Names
Please list institution and last four digits of account number.
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Husband's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Husband's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Husband's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Wife's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Wife's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Checking / Savings Account Titled in Wife's Name Only
Please list institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Other Checking / Savings Account
Please list how titled, institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Other Checking / Savings Account
Please list how titled, institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
Other Checking / Savings Account
Please list how titled, institution, type of account and last four digits of account number
Your answer
Range of Account Value During One Month Period
Your answer
LIFE INSURANCE
Do you have any employer provided life insurance?
Amount of Death Benefit for Employer Provided Life Insurance
Your answer
Life Insurance Policy #1 Titled in Husband's Name
Include Name of Policy, Death Benefit and Cash Surrender Value (if any)
Your answer
Type of Life Insurance for Husband Policy #1
Life Insurance Policy #2 Titled in Husband's Name
Include Name of Policy, Death Benefit and Cash Surrender Value (if any)
Your answer
Type of Life Insurance for Husband Policy #2
Life Insurance Policy #1 Titled in Wife's Name
Include Name of Policy, Death Benefit and Cash Surrender Value (if any)
Your answer
Type of Life Insurance for Wife Policy #1
Life Insurance Policy #2 Titled in Wife's Name
Include Name of Policy, Death Benefit and Cash Surrender Value (if any)
Your answer
Type of Life Insurance for Wife Policy #2
Other Life Insurance
including life insurance on children
Your answer
STOCKS, INVESTMENT ACCOUNTS & MONEY MARKET ACCOUNTS
DO NOT include retirement accounts such as 401K's and IRA's in this section (see retirement account section below for that information). Where applicable, include assets such as vested and unvested stock options and stock units.
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Joint Names
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Joint Names
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Husband's Name
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Husband's Name
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Wife's Name
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
NON RETIREMENT Stock / Investment Accounts, Money Market Accounts in Wife's Name
Please provide institution name and last four digits of account number.
Your answer
Approximate Market Value of Above Account
Your answer
Additional NON RETIREMENT Stock / Investment Accounts, Money Market Accounts
if not listed above (Please provide institution name and last four digits of account number).
Your answer
COLLEGE SAVINGS ACCOUNTS
College Savings Account
Include name of institution, last four digits of each account and custodian on account.
Your answer
Approximate Market Value of Above Account
Your answer
College Savings Account
Include name of institution, last four digits of each account and custodian on account.
Your answer
Approximate Market Value of Above Account
Your answer
College Savings Account
Include name of institution, last four digits of each account and custodian on account.
Your answer
Approximate Market Value of Above Account
Your answer
RETIREMENT ACCOUNTS
Include accounts such as 401K's, IRA's and pension plans.
Retirement Account in Husband's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Retirement Account in Husband's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Retirement Account in Husband's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Retirement Account in Wife's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Retirement Account in Wife's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Retirement Account in Wife's Name
Please provide institution name and last four digits of account number.
Your answer
Type of Account
Approximate Market Value of Above Account
Your answer
Please briefly describe any additional retirement accounts
Your answer
BUSINESS INTERESTS
Business Interest
include name of business, percent of ownership, nature of business conducted, business type (S-Corporation, LLC, sole proprietorship, etc) and how titled
Your answer
Business Interest
include name of business, percent of ownership, nature of business conducted, LLC, business type (S-Corporation, sole proprietorship, etc) and how titled
Your answer
ADDITIONAL ASSETS NOT OTHERWISE LISTED
Including Country Club Memberships, Oil and Gas Rights, Frequent Flyer Miles, Livestock/Farm Equipment/Crops, Vacation Club Points, Money / Loans Owed to You, Pending Lawsuit or Claims, Safety Deposit Box, Health Savings Accounts, Tax Refunds, Trusts, Accrued Paid Leave, Mineral and Water Rights. Please include the type of asset listed as well as estimated value.
Additional Assets Not Included Above
Your answer
Additional Assets Not Included Above
Your answer
UNSECURED DEBTS
For each debt please include name of creditor (i.e. Visa, American Express, etc.) and last four digits of each account. For this questionnaire you only need to include the name of those debts not paid in full on a monthly basis. DO NOT include secured debts listed above (i.e. mortgage obligations, motor vehicle liens). In order to confirm how these debts are listed with creditors, you may want to consider running your FREE credit report on www.AnnualCreditReport.com.
Unsecured Debt Titled in Joint Names
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Joint Names
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Joint Names
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Joint Names
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Husband's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Husband's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Husband's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Husband's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Wife's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Wife's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Wife's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Unsecured Debt Titled in Wife's Name Only
name of creditor and last four digits of account number
Your answer
Current Balance of Above Debt
Your answer
Additional Unsecured Debts Not Included Above
include student loans in the names of children
Your answer
Additional Unsecured Debts Not Included Above
include student loans in the names of children
Your answer
TAXES
Have you filed your tax returns for the year 2018?
Have all refunds been received or liabilities paid for your 2018 tax returns?
For all the years of your marriage, do you have any outstanding tax returns to be filed, or outstanding tax refunds or tax liabilities?
If yes to the above (regarding outstanding tax issues) please explain.
Your answer
PRE NUPTIAL / POST NUPTIAL AGREEMENT / SEPARATE PROPERTY
Did you and your spouse sign any legally binding agreements during your marriage pertaining to the allocation of assets and debts and / or support in the event of a divorce or legal separation?
In other words, did you and your spouse sign a pre-nuptial or post nuptial agreement?
For any of the assets or debts described above, were those acquired before the marriage, or by gift or inheritance during the marriage?
If yes, please explain. We will discuss this issue further in mediation.
Your answer
Is there any additional information that you would like to provide to your mediator in order to better assist him or her in mediating your case?
If applicable, please include information regarding discussed settlement terms and/or areas of disagreement or concern.
Your answer
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