Appendix D. Pretrial Conference Statement Rule 8.3

STATE OF NORTH DAKOTA )In District Court County of ___________. )_________ Judicial District Civil No. ________ A.B., Plaintiff ) RULE 8.3, NDROC, vs. ) PRETRIAL CONFERENCE C.D., Defendant ) STATEMENT 1 . PERSONAL INFORMATION Full Name____________ Present Mailing Address ____________ Employer____________ Street Address ____________ City, State, Zip ____________ Birth date and present age ___________ Marriage Date____________ Separation Date (Different Residences) ____________ Date(s) of Temporary Order(s), if any ____________ Minor children born to this marriage or who will be affected by this legal action: INITIALS____________ BIRTH YEAR____________ AGE____________ LIVING WITH____________ Is the wife pregnant? _____ Yes _____ No. If yes, the due date is ____________. Are parenting rights and responsibilities of any child contested? ____yes ____No. If yes, attach your proposed parenting plan for each child. 2. EMPLOYMENT/INCOME Provide the following data for each employer. HUSBAND WIFE A) Name of Employer ____________ Length of Employment ____________ Income Per Month: 1) Gross income____________ Guideline deductions: Federal Income Tax ____________ State Income Tax ____________ FICA/Medicare____________ Health Insurance for children____________ Union Dues ____________ Mandatory Retirement____________________________ (2) Subtotal of Guideline Deductions ____________ (3) Net Income (Line 1-Line 2) ____________ Other guideline considerationsSpecify:____________ (4) Subtotal of Other Deductions____________ (5) NET TAKE HOME PAY ____________ (Line 3-Line 4) Tax withholding figures above are based upon Married or Single tax- payer with # of exemptions: (Example M-4 or S-2) ____________ B) Employment benefits: Identify all benefits in addition to wages including bonuses paid or due, automobile or travel expense reimbursement, other per diem compensation, memberships paid by the employer or in kind benefits. ____________ C) Other Income: (1) Public Assistance Per Month (AFDC/GA) ____________ (2) Social Security, Including ChildBenefits, PerMonth ___________________________________ (3) Unemployment/ Workers Comp Per Month ___________________________________ (4) Interest Income Per Month ____________ (5) Dividend Income Per Month ____________ (6) Other Income Per Month ____________ (7) Last Year's Tax Refunds Federal ____________ Federal ____________ State____________ State____________ 3. CHILD SUPPORT/SPOUSAL SUPPORT A) Child or spousal support established in separate proceeding: (1) Is either party entitled to child or spousal support from a separate proceeding? Yes____ No____. If yes, for each party entitled to child or spousal support, specify the amount: $____________. (2) Is either party required to pay child or spousal support from a separate proceeding? Yes____ No____. If yes, for each party required to pay child or spousal support, specify the amount: $________. B) Child or spousal support established by temporary order in this proceeding: (1) Is either party required to pay child or spousal support under a temporary order in this proceeding? Yes____ No____. If yes, specify the amount: Child Support $___________. Spousal Support $_________. (2) Is any arrearage claimed under an existing temporary order? Yes____ No____. If yes, specify the amount: Child Support $_________. Spousal Support $_________. 4. LIVING EXPENSE S Specify the amount of your total monthly expenses $__________; and attach an itemized list of your monthly expenses. 5.REAL PROPERTY: (For Each Parcel of Property) 1. Description of Property_______________________ (a) In Possession of_______________________ (b) Date Acquired _______________________ (c) Purchase Price $______________________ (d) Present FMV(Date of Valuation)$______________________ (e) First Mortgage Bal.$______________________ (f) Second Mortgage Balance or Home Improvement Loan $______________________ (g) Net Value$______________________ (h) Monthly Payment$______________________ (i) Income from Property$______________________ 6. BUSINESS/FARM ASSETS (For Each Asset) 1. Description of Asset_______________________ (a) In Possession of_______________________ (b) Date Acquired/Age _______________________ (c) Purchase Price $______________________ ( d) Present FMV (Dateof Valuation) $______________________ (e) Debt Balance$______________________ (f) Net Value$______________________ (g) Monthly Payment $______________________ (h) Income from Property$______________________ 7. FINANCIAL ASSETS (For Each Asset) 1. Description of Asset_______________________ (a) In Possession of_______________________ (b) Date Acquired/Age _______________________ (c) Purchase Price $______________________ (d) Present FMV (Dateof Valuation) $______________________ (e) Debt Balance$______________________ (f) Net Value$______________________ 8. LIFE INSURANCE (For Each Policy) a) Name of Company _________________ b) Policy No. _________________ c) Type of Insurance _________________ d) Face Amount _________________ e) Cash Value _________________ f) Loans _________________ g) Insured _________________ h) Beneficiary _________________ i) Owner _________________ 9. PENSION PLAN AND/OR PROFIT SHARING PLAN Husband Wife (a) Through employment: (1) Value (b) Private Plans(IRA, Keogh, SEP)Value (c) Deferred Compensation Value (d) Military Pension or Disability Yes_ No_ Yes_ No_ 10. PERSONAL PROPERTY: (For Each Asset) A. Household Items in Husband's Possession Description of Item Value 1. _____________________________ B. Household Items in Wife's Possession Description of Item Value 1. _____________________________ C. Household Items in Joint Possession Description of Item Value 1. _____________________________ D. Motor Vehicles (For Each Asset) 1. Year, Make, Model________________ (a) In Possession of________________ (b) Market Value ________________ ( c) Encumbrances ________________ (d) Net Value________________ (e) Monthly Payments________________ E. Boats, Campers, Snowmobiles, Trailers (For Each Asset) 1. Year, Make, Model_________________ a) In Possession of_________________ (b) Market Value _________________ (c) Encumbrances _________________ (d) Net Value_________________ (e) Monthly Payments_________________ F. Other Personal Property (For Each Asset) 1. Description of Item_________________ (a) In Possession of_________________ (b) Market Value _________________ (c) Encumbrances _________________ (d) Net Value_________________ (e) Monthly Payments_________________ 11. DEBTS (Not listed previously) A) 1. Secured debts: (a) Creditor_________ (b) Total Amount Owing $________ (As of What Date)_________ (c) Monthly Payments$________ (d) When Incurred_________ (e) Party Obliged_________ (f) Collateral_________ (g) Date of final payment_________ TOTALS: Husband ________ Wife ____________ Joint ____________ B) 1. Unsecured debts: (Include Attorney's Fees and Costs) (a) Creditor____________ (b) Total Amount Owing$________ (As of What Date)____________ (c) Monthly Payment$________ (d) When Incurred_________ (e) Party Obliged_________ (f) Consideration____________ (g) Date of final payment____________ TOTALS:Husband ____________ Wife ____________ Joint ____________ I hereby represent that the above is a complete disclosure of all property interests and liabilities, and that the values set forth are the best estimates of the property's market value. ____________[Plaintiff] [Defendant] ____________Attorney for [Plaintiff] [Defendant] ______________________________________ Attorney Identification Number ______________________________________ Address