FORM 70.09E

No.

IN THE SUPREME COURT OF NOVA SCOTIA

(FAMILY DIVISION)

BETWEEN:

*[A. B.]

- and -

*[C. B.]

Applicant/Petitioner

Respondent

STATEMENT OF PROPERTY

OF *[name]

DATE PREPARED: *[date]

I, *[name], of *[location], Nova Scotia, make oath and say that particulars of all my property and debts and of all my property and debts that I hold jointly with *[name] are accurately set out below, to the best of my knowledge, information and belief.

Real Estate

Ownership	Nature and Address of Real Estate	Value as of *(date)

Household items
(Show items by major category, e.g. appliances, furniture and household effects, jewellery, etc. List major items in each category and identify which party currently has possession of the item)
Category	Possession	Major Items	Value as of *(date)

Vehicles
(Give make, model and year for automobiles, boats and other vehicles and identify which party currently has possession of the vehicle and current market value.)
Make, Model and Year	Possession	Value as of *(date)

Pensions
(If you have a pension, attach your most recent annual pension statement and any further information you have explaining your pension plan.)
Category	Institution	Value as of *(date)

R.R.S.P.s
(If you have a registered retirement savings plan, specify the institution where it is held, the account number and the present amount. Attach any recent statements from the institution where your RRSP is held.)
Category	Institution	Account Number	Value as of *(date)

Savings and other accounts
(Show all accounts, setting out the type of account, in what names it is held, the financial institution where it is held, the account number and the present amount in the account. Even if there no current balance in the account, provide the particulars and indicate a zero balance. Any other savings or cash holding, other than securities should be shown here.)
Category	Institution	Account Number	Value as of *(date)

Securities
(Show items by category, e.g. shares, bonds, mutual funds, warrants, options, debentures, notes and any other securities and identify if it is held in your name or jointly. Set out category, description, number, and estimated market value.)
Category	Number	Description	Estimated Value as of *(date)

Life and Disability Insurance
(Set out company, policy number, owner, beneficiary, face amount and cash surrender value, if any.)
Company	Policy No.	Owner Beneficiary	Face Amount	Cash Surrender Value as of *(date)

Accounts Receivable
(Give particulars of all debts owing to you.)
Particulars	Amount as of *(date)

Business Interests
(Show any interest in a business, whether incorporated or unincorporated, not set out above. Set out the nature of the firm or company, your interest and its current estimated value.)
Nature of Firm or Company	Interest	Estimated Value as of *(date)

Other
(Show any other property not included in the above categories.)
Category	Estimated Value as of *(date)

Debts
(Show debts by category, e.g. mortgages, loans, credit cards, charges, liens and notes payable. Include any contingent liabilities such as guarantees. Show the identity of any property affected by any mortgages or charges. Set out category, particulars of the debt (including whether a joint debt or not, interest rate, term or number of payments remaining, any property affected, and present amount.)
Category	Institution	Particulars	Amount Owing as of *(date)

SWORN TO at *[location], in the County of *[name of county], Province

of Nova Scotia, this *[date] day of

*[month], *[year], before me

_________________________________

A Barrister, Notary or Commissioner of Oaths for the Province of Nova Scotia

)

________________________________

*[name]