SEPARATION AGREEMENT & PROPERTY SETTLEMENT

QUESTIONNAIRE

Bagwell Holt Smith Jones & Crowson, P.A.

111 Cloister Court, Suite 200, Chapel Hill, NC 27514

Attorney: John G. Miskey IV

Telephone: 919.401.0062

Fax: 919.403.0063

Email: jmiskey@bhspa.com, ncfamilylawyer@gmail.com

Instructions: Congratulations on your decision to settle your disputes arising from your marriage with a separation agreement and property settlement agreement. The purpose of this worksheet is to gather the information necessary to assist us in preparing your agreements. It is important that we have the following understanding before proceeding further:

1. We represent you as our client. We do not represent your spouse, and we do not represent you and your spouse as a couple in negotiating and preparing your agreements. It is urged that your spouse obtain separate and independent legal counsel for advice in this process.

2. You and your spouse must provide a full and fair disclosure of all financial information requested in these worksheets for us to help you negotiate and prepare your agreements. Failure to do so may make it necessary to file a lawsuit to force disclosure of information from your spouse if he or she withholds vital information that is necessary to the agreement.

3. Make sure your spouse understands that you have hired our firm to assist you in the negotiation and preparation of a separation agreement and property settlement agreement. If your spouse indicates that he or she has also hired an attorney, contact us immediately. It is not appropriate for you to obtain information from her or him about financial or other matters for us if he or she is represented by an attorney. If your spouse indicates he or she has hired an attorney, do not be alarmed. We may still be able to assist you in negotiating a fair settlement that meets your legal objectives without litigation.

4. The separation agreement is contingent on you and your spouse continuing to live separate and apart. That does not mean that you must avoid each other. You may still go out on dates, and even have isolated occasions where intimate relations occur. However, should you and your spouse separate, sign the agreement, and then resume the marriage by cohabiting under the same roof again, the agreement will be void. A separation agreement is not required to obtain an absolute divorce. If you have questions about this, discuss it further with your attorney.

5. The laws with respect to marital agreements vary from state to state. Your agreements will become valid and enforceable in the State of North Carolina. However, should you and your mate choose to establish a residence in another state, that state's court may choose not to enforce the agreement, or some provision of the agreement, that may be against that state's public policy or laws.

6. You should complete this worksheet in as much detail as possible. Your spouse can voluntarily assist you in this process, provided he or she understands that we do not represent him or her. Once all of the information is gathered, we can begin preparation of the agreements.

If you have any question about, or need clarification of, any of these matters, please contact our office immediately.

I. PERSONAL INFORMATION

Full Name of Client: ________________________________________________

Social Security Number:

Address: ___________________________

___________________________

___________________________

Home Phone: ________________________

Mobile Phone: ________________________

Work Phone:

Full Name of Spouse: ________________________________________________

Social Security Number:

Address: ___________________________

___________________________

___________________________

Home Phone: ________________________

Mobile Phone: ________________________

Work Phone:

Date of Marriage: _______________

Place of Marriage: _____________________

Children: Age: DOB:

Full Name: _____________________ ________ ________

Full Name: _____________________ ________ ________

Full Name: _____________________ ________ ________

Full Name: _____________________ ________ ________

II. SEPARATION

•1. You do not need a separation agreement to obtain a divorce, so if that is the reason you are seeking a separation agreement, discuss this with your attorney. You should not leave the marital residence or separate until your attorney has told you that it is legally permissible for you to do so. Your leaving could be construed as an abandonment. If you have already separated, or you are about to separate, please state the intended date of separation. For purposes of your agreement, separation means ceasing to live together under one roof.

•2. Date of separation or intended separation:

•3. Have you lived continuously separate and apart since the date of separation stated above? Isolated incidences of sexual relations do not generally constitute a resumption of marital relations. Discuss any questions about whether your separation has been continuous with your attorney.

III. EMPLOYMENT AND INCOME

Name of employer: ________________________

Address of employer: ________________________

________________________

Years employed: ________________________

Person to contact to obtain wage information: _________________________

* Attach a copy of your four most recent wage receipts or verification of income from January 1st of this year to the present date.

Name of Spouse's employer: ________________________

Address of employer: ________________________

________________________

Years employed: ________________________

Person to contact to obtain wage information: _________________________

* Attach a copy of your spouse's four most recent wage receipts. If possible, include verification of income from January 1st of this year to the present date.

* Provide a copy of tax returns for the three (3) years. If you and your spouse did not file joint tax returns, provide a copy of your tax returns and your spouse's tax returns for the two (2) calendar years.

Describe any other income you or your spouse receives, e.g. rental income: _____________________________________________________________

IV. PROPERTY

•1. It is absolutely essential that your attorney have a complete list of all of your assets (properties) and liabilities (debts) in order to advise you on your property settlement. Failure to disclose property or debts may have legal consequences such as the agreement being declared invalid.

•2. The court only has authority to divide and distribute marital property. Any separately owned property remains the property of the person whose name is on the title.

•3. The court generally makes an equal division of marital property; however, in some cases the court may make an unequal division. For more information about the division in your case, ask your attorney.

•4. "Separate property" is property acquired prior to the marriage, after separation, acquired by inheritance at any time, or acquired by gift directly to one spouse at any time. "Marital property" is all other property acquired during the marriage and before separation. Items acquired during the marriage by inheritance or gift to both spouses is marital property. You should disclose all of your property, whether marital or separate, and indicate your opinion about why property should be classified marital or separate. All property is valued on the date of separation. Please disclose your opinion on the net fair market value of each item of property listed regardless of whether you list the property as marital or separate.

•5. Should you have questions concerning whether you may be entitled to more than one-half of the marital property, do not hesitate to discuss the matter with your attorney. There are many factors the judge may consider in deciding whether a division of property will be equal. These will be discussed with your attorney at your request. If you are unable to list all the information requested in the space provided, attach additional sheets.

A. Real Estate

Primary Residence:

In connection with all real estate owned by you or your spouse, provide the following:

•1. Complete address or brief description (attach a copy of the deed if available):

___________________________________________________________

___________________________________________________________

2. Was property purchased, inherited, received as a gift? __________

Date purchased, inherited or received as a gift: __________

3. If purchased, original purchase price and source of funds used to purchase: _____________________________________________________________

4. Fair market value of property as of date of separation (attach a copy of a recent appraisal if available): ______________________________________________

5. Outstanding mortgages and/or liens on property as of date of separation:

Name of lender Balance

_____________________ ________

_____________________ ________

•6. Net fair market value (fair market value less mortgages and liens) of property as of date of separation: ___________________________________________

•7. Proposed distribution of property to husband or wife: _________________

•8. Is property to be sold? _________________________________________

•9. Who has made payments since the separation, and the amount of said payments? ____________________________________________________________

•10. Describe any improvements and the cost of such improvements: _____________________________________

* Please attach mortgage payment history for the past twelve (12) months.

Second Home or Investment Property:

•1. Complete address or brief description (attach a copy of the deed if available):

___________________________________________________________

___________________________________________________________

2. Was property purchased, inherited, received as a gift? __________

Date purchased, inherited or received as a gift: __________

3. If purchased, original purchase price and source of funds used to purchase: _____________________________________________________________

4. Fair market value of property as of date of separation (attach a copy of a recent appraisal if available): ______________________________________________

5. Outstanding mortgages and/or liens on property as of date of separation:

Name of lender Balance

_____________________ ________

_____________________ ________

•6. Net fair market value (fair market value less mortgages and liens) of property as of date of separation: ___________________________________________

•7. Proposed distribution of property to husband or wife: _________________

•8. Is property to be sold? _________________________________________

•9. Who has made payments since the separation, and the amount of said payments? ____________________________________________________________

•10. Describe any improvements and the cost of such improvements: _____________________________________________________________________

* Please attach mortgage payment history for the past twelve (12) months.

B. Automobiles, Boats, Other Vehicles

In connection with each motor vehicle owned by you or your spouse, provide the following:

1. Describe who made payments since the separation and the amount of these payments?

______________________________________________________________________

_______________________________________________________________________________

•2. Describe any repairs and the cost of such repairs:

______________________________________________________________________

_______________________________________________________________________________________

•3. Who will pay for liability, collision or other insurance for each vehicle:

______________________________________________________________________

____________________________________________________________________________________

* Please attach Kelley Blue Book or NADA summary for each automobile, boat or other vehicle.

C. Interests in Sole Proprietorships, Partnerships, or Other Business Interests

With respect to businesses in which you or your spouse own an interest, state:

1. Business name and address: _________________________

_________________________

_________________________

•2. Percentage of interest owned: ________________________

•3. Business organized as: (e.g. sole proprietorship): ___________________

•4. Date purchased, inherited or received as a gift: _____________________

•5. Original purchase price: _______________________________________

•6. Source of funds used to purchase: _______________________________

•7. Net fair market value of business interest as of date of separation: ______

•8. Net fair market value of business interest as of the present: ___________

•9. Proposed distribution of business interest: _________________________

* Please attach all business profit and loss statements.

* Please attach all appraisals.

D. Stocks and Bonds

Make a list of all stocks and bonds held by you or your spouse. State their values on the date of separation. This information may be obtained from stock listings on that date if the stock is traded on an exchange such as the NASDAQ, American, or New York Stock Exchange. If the stock is not traded on an exchange, discuss this matter with your attorney to obtain the proper value. Include debentures, stock options, and futures. State how these assets are to be divided:

Distribution: ____________________________________________________________

__________________________________________________________________

* Please attach statements for the previous twelve (12) months for stocks, bonds and investments.

E. Bank Accounts

In connection with each bank account (money market, certificate of deposit, savings account, checking account, business account), state the following:

* Please attach statements for the previous twelve (12) months for all savings, checking, money market accounts and CDs.

F. Insurance

For each policy of life, health, or disability insurance in effect on the date of your separation, state the following:

* Please attach document verifying the above Insurance information.

G. Pension and Retirement Benefits

If any of your property includes vested or nonvested pension or retirement benefits, 401(k) plans, deferred compensation benefits, individual retirement accounts or military retirement benefits under the federal Uniformed Services Former Spouses' Protection Act, then with respect to each benefit state the following (you may need the assistance of your employer or plan administrator to complete this part):

Client's Pension or Retirement Benefits:

•1. Name of employer: ___________________________________________

•2. Account holder: _____________________________________________

•3. Type of benefit: ______________________________________________

•4. Name of plan administrator: ____________________________________

•5. Address of plan administrator: __________________________________

•6. Nature of benefit payable under plan: ____________________________

•7. Beginning date of payments: ____________________________________

•8. Total value of benefit as of date of separation: ______________________

•9. Total value of benefits as of the present: __________________________

•10. Total value of benefits when payments will commence: _______________

•11. How payments are to be made: _________________________________

•12. Amount paid or to be paid: _____________________________________

•13. Proposed distribution: _________________________________________

* Please attach statements of the past three (3) years of the 401(k), pension or other retirement account.

Spouse's Pension or Retirement Benefits:

•1. Name of employer: ___________________________________________

•2. Account holder: _____________________________________________

•3. Type of benefit: ______________________________________________

•4. Name of plan administrator: ____________________________________

•5. Address of plan administrator: __________________________________

•6. Nature of benefit payable under plan: ____________________________

•7. Beginning date of payments: ____________________________________

•8. Total value of benefit as of date of separation: ______________________

•9. Total value of benefits as of the present: __________________________

•10. Total value of benefits when payments will commence: _______________

•11. How payments are to be made: _________________________________

•12. Amount paid or to be paid: _____________________________________

•13. Proposed distribution: _________________________________________

* Please attach statements of the past three (3) years of the 401(k), pension or other retirement account.

H. Household Goods, Appliances, Metals, Collections, Antiques and Personal Items, Including Jewelry (Not Otherwise Listed in These Worksheets)

•1. Make an inventory for each spouse of all household goods, appliances, and other personal property which you have in your possession and which you have not listed above. The inventory should contain a list of "marital property" and a list of "separate property" for each spouse. All items that were acquired by a spouse prior to marriage, inherited items, and items received as gifts solely to one spouse should be placed on that spouse's list of inventory as "separate" property items. All other items are "marital" property items. Items on the separate property inventory for a spouse shall remain the property of that spouse. Marital property items must be divided equitably. Assign a value at date of separation for all items on marital property inventory.

•2. You and your spouse should attempt to divide all items on the marital inventory in a mutually agreeable fashion. Make a list of items that are in controversy, and report those items to your attorney.

•3. Items on the separate property inventory for a spouse shall remain the property of that spouse. You and your spouse should attempt to divide all items on the marital inventory in a mutually agreeable fashion. Highlight the items that are in controversy and report those items to your attorney.

•4. Note: Generally, the courts will divide marital items on an equal basis so that each spouse will have items of equal value. If you cannot agree on marital items, you will have to provide the information requested above for your real estate and vehicles for each item of property. This may prove time consuming and costly to you and your spouse. Your separation agreement will contain either a list of all items for each party or a statement that you have already divided all items and neither party will claim items now held by the other.

V. DEBTS AND LIABILITIES

With respect to each debt or liability owed by you or your spouse on the date of separation, state the following:

1. Name of creditor, last four digits of account number and date of separation balance:

2. Have you or your spouse filed a bankruptcy proceeding? _____________

•3. If so, state the court in which it was filed, the name of the case, the date it was filed, and the case number if available:

______________________________________________________________________________________

•4. Please describe all unliquidated or contingent debt, lawsuit, or tax liability which is not pending or due at this time but may be asserted against you or your spouse within the next five (5) years, if any:

________________________________________________________________________________

•5. Summary: After considering the values of all items of real and personal property and the liabilities and debts to be distributed, have you made a relatively equal division of all the marital property? If not, will it be necessary for the spouse receiving less than one-half to be paid a distributive award in lump sum cash or monthly payments to compensate for the unequal division of property? If so, state the amount and method of payment or payments: _______________________________________

________________________________________________________________________________________________

* Please attach the previous 12 months of credit card statements.

VI. CHILD CUSTODY

•1. If you and your spouse have minor children, you should complete this section.

•2. PLEASE USE THE PARENTING AGREEMENT WHICH WE HAVE PROVIDED TO YOU FOR WORKING OUT THE TERMS OF A PROPOSED PARENTING AGREEMENT TO BE ATTACHED TO YOUR AGREEMENT.

•3. A decision must be made concerning the form of custody arrangement that you feel will be in the best interest of your child(ren). For purposes of child support, sole custody becomes joint or shared custody when each spouse has the child more than 122 nights per year.

•4. Is there presently any dispute concerning whether the husband is the father of any child? If so, explain:

__________________________________________________________________________

•5. Do you agree that both parents are fit and proper persons to have custody and visitation rights with the child(ren)? If not, explain:

___________________________________________________________________

•6. You should plan a visitation schedule taking into consideration the work schedules of each party and the schedules of the child(ren).

Visitation:

A decision must be made concerning the form of custody arrangement that you and your spouse decide will be in the best interest of your child(ren). The options are basically as follows (check the option you and your spouse elect):

_____ Sole custody--visitation. Under this arrangement, one spouse has

custody of the child(ren) and the other has visitation rights.

_____ Sole custody--temporary custody. Under this arrangement, one spouse

has custody during certain times, while the other has temporary

custody during certain times.

_____ Joint or shared custody. Under this arrangement, each parent has

custody of the child(ren). Although this may appear good in theory,

it often does not work well because there is no set structure for

the child(ren). For purposes of child support, sole custody becomes

joint or shared custody when each spouse has the child more than 122

nights per year.

_____ Split custody. Under this arrangement, one parent has custody of one

child, while the other parent has custody of another child.

Do you wish to have the following special provisions?

_____ 1. Noncustodial parent to pay for transportation costs for visitation.

_____ 2. Neither parent allowed to take a child out of the U. S. without prior

written consent.

_____ 3. Sixty (60) days' written notice to the other party before moving

residence.

_____ 4. Neither party to stay overnight with person of opposite sex to whom

they are not related.

_____ 5. Both parents to have equal access to medical and school records.

_____ 6. Each party to notify the other if a child is ill.

_____ 7. Each party authorized to seek emergency medical care.

_____ 8. Which parent will serve as administrator of the child's estate should

the child die.

_____ 9. Parents to confer on important matters such as discipline, special events, etc.

Please detail other special provisions or considerations concerning custody:

_________________________________________________________________________________________

VII. CHILD SUPPORT

•1. A copy of the guidelines for child support with worksheets has been provided to you with this worksheet. At this point you should consult that worksheet in arriving at an amount of child support to be paid by the noncustodial spouse to the spouse with custody. Should you have questions, please do not hesitate to ask your attorney for assistance.

•2. Does either spouse carry medical insurance on the child(ren)? If so, will that spouse agree to continue such coverage?

_____________________________________________________________________________

•3. Note: The court will usually order the noncustodial spouse to maintain such coverage and pay his/her proportionate amount based on the guidelines (use percentage of income) of the uninsured health care related expenses in addition to child support.)

•4. Is child support to be an obligation of the noncustodial spouse's estate? (Child support is not usually an obligation of the estate, but the parties may agree to this provision, and it will be enforced.) __________________________________________

•5. Is child support to continue past age eighteen (18)? _________________

•6. Is the noncustodial spouse agreeing to pay for college expenses? If so, enumerate expenses to be covered, such as tuition, room, board, lab fees, books, travel, monthly allowance:

_____________________________________________________________________________

•7. Is payment of child support to be secured by a life insurance policy or disability insurance policy? _______________________________________________

Child Support Summary Breakdown:

VIII. TAXES

•1. Usually spouses file joint tax returns for the year in which they separate and all other years allowed by law. After the divorce is final, you must file separate returns. Are you going to file joint returns for as long as allowed by law? ____________

•2. The tax dependency exemption for a child or children is usually allowed by law to the custodial parent, unless the custodial parent agrees to sign a waiver of the exemption. When there is one child, the parties may alternate the exemption between even and odd number years for that child. When there are two or more children, the dependency exemption for each child may be allocated between the parents to provide a benefit each year. Please state your preference: _____________________________

•3. The party paying child care expenses ordinarily receives the child care credit on his or her tax return.

•4. You may elect to file joint tax returns until you are divorced. Most parties elect to file joint tax returns for the year in which they separate and all other years allowed by law. After your divorce is final, you must file a separate return. Please state your preference: ________________________________________________________

•5. How are you going to handle any refunds or liabilities created from such returns? _______________________________________________________________

IX. ALIMONY AND POSTSEPARATION SUPPORT

•1. The question of whether a spouse is entitled to alimony and/or postseparation support from the other spouse is often a complex legal question. Generally, an economically-dependent spouse who has been married for a period of time from the supporting spouse. Whether a spouse is entitled to alimony and postseparation support should be discussed with your attorney before you make a decision.

•2. Generally, one spouse must be dependent upon the other spouse for his or her support and maintenance.

•3. Marital misconduct comes into play with respect to post-separation support and alimony.

•4. Although a number of factors may be considered, the key factors in determining the amount and duration of alimony payments are the needs of the dependent spouse, the prior standard of living of the parties and support spouse's ability to pay.

•5. Once it is determined that alimony is to be paid, the amount is usually based on the prior standard of living of the dependent spouse and the supporting spouse's ability to pay.

•6. Alimony generally does not terminate until the death of the supporting spouse or the death or remarriage of the dependent spouse.

•7. Alimony may be subject to increase or decrease by the court by showing a change in circumstances.

•8. Alimony may be made in lump-sum or in periodic payments.

•9. Alimony payments are ordinarily deductible to the party making the payments and are taxable income to the party receiving the payments.

•10. Are both parties willing to waive payment of post-separation support and alimony by the other? ___________________________________________________

•11. If post-separation support and/or alimony payments are requested, list expected monthly cost of living expenses:

•12. Amount of post-separation support and/or alimony to be paid is $____________.

•13. If alimony is to be paid, what is the preferred method, e.g. monthly, weekly? _______________________________________________________________

•14. Does either spouse carry medical insurance on the other spouse?

•15. If so, will that spouse agree to continue such coverage?

•16. Note: the court will usually order the supporting spouse to maintain such coverage for the dependent spouse, and pay all of the uninsured health care related expenses of the dependent spouse in addition to post-separation support and/or alimony. The insurance plan may state that this coverage must terminate upon the divorce, but that COBRA coverage is available following divorce.

•17. Please note if COBRA coverage is available following divorce and the cost of such coverage: _______________________________________________________

•18. Is postseparation support and/or alimony to be an obligation of the supporting spouse's estate? _______________________________________________

•19. Post-separation support and alimony are not usually the obligation of the estate, but the parties may agree to this provision and it will be enforced.

•20. Is payment of post-separation support and/or alimony to be secured by a life insurance policy or disability insurance policy, deed of trust on property, wage withholding, etc.? _______________________________________________________

X. MISCELLANEOUS

•1. In the event that you reconcile (resume your marriage) after signing the separation agreement and property settlement, do you want the agreement to continue in effect until you enter into a written reconciliation agreement? ___________________

•2. Do you understand that the agreement will settle all of your rights against the other spouse arising out of the marriage and you can never again seek to enforce these rights, except as provided in the agreement? _____________________________

•3. Do you understand that if you fail to abide by the provisions of the separation agreement, you may be sued and you may be required to pay attorney's fees and costs if you have violated the agreement? ________________________________

•4. Have you been under any coercion, undue influence, or been threatened in any way to cause you to enter into the separation agreement and property settlement? ____________________________________________________________

•5. Do you understand that each party has the right to have the agreement reviewed by his or her own attorney? ________________________________________

•6. Is either party any party of the other party's attorney's fees? ___________

I HEREBY CERTIFY THAT THE INFORMATION PROVIDED ABOVE AND ON THE ATTACHED SHEETS IS COMPLETE, TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF.

________________________ (SEAL) Date: ________________________