3. List your spouse’s employment history, most recent employer first. (Gross monthly pay is before taxes or other deductions.) Employer Address Dates of Employment Gross Monthly Pay 4. How much cash do you and your spouse have? $ _________________________ Below, state any money you or your spouse have in bank accounts or in any other financial institution. Financial Institution Type of Account Amount You Have Amount Your Spouse Has If you are a prisoner, you must attach a statement certified by the appropriate institutional officer showing all receipts, expenditures, and balances during the last six months in your institutional accounts. If you have multiple accounts, perhaps because you have been in multiple institutions, attach one certified statement of each account. 5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishing. Home Value Other real estate Value

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