FINANCIAL DISCLOSURE STATEMENT


Case # Judge: Branch:

Husband's Attorney:
_______________________________________

Husband:
Address:

Birthdate:
Social Security No.:
Employer:
Address:

Date of Marriage:

Wife's Attorney:
_______________________________________

Wife:
Address:

Birthdate:
Social Security No.
Employer:
Address:

Date of Separation:

Children: Birthdate Children: Birthdate


With whom are children living:

1. STATEMENT OF INCOME:
Last Year's Income Tax Refunds:
H W Joint
Gross current monthly income from: HUSBAND WIFE

Salary & wages, commissions, allowances, overtime
(Note: To arrive at monthly income figure if paid weekly,
multiply, wkly income by 52 and divide by 12. If paid
bi-wkly, multiply bi-wkly income by 26 and divide by 12.)
Pensions and retirement
Social Security Benefits
Disability and/or Unemply.comp.benefits
Public assistance (i.e. Welfare, AFDC Pmts.)
Child support from any prior marriage
Dividends and interest
Rents
Bonuses (annual, semi-annual, or quarterly)
All other sources
TOTAL MONTHLY INCOME $

Itemize monthly deductions from gross income:
Number of tax exemptions claimed for
payroll deductions: H W
Federal Income Taxes
State Income Taxes
Social Security
Medical Insurance
Other Ins. (describe)
Union or other dues
Retirement or pension fund
Savings plan
Credit Union, debt repayment
Other: (specify)

TOTAL MONTHLY DEDUCTIONS $ $
NET MONTHLY INCOME TAKE HOME PAY $ $

2. STATEMENT OF MONTHLY EXPENSES:
Specify the number of members in each household whose expenses are included, also list their names and relationships:
Husband ()
Wife ()
HUSBAND CHILDREN WIFE
Total Portion Total
Household Household
a) Rent or mortgage payments, Prin, Interest,
taxes, Ins. if in one payment
b) Real property taxes & insurance
c) Repairs/maintenance of residence, appliances,
furnishings, cable TV, garbage pickup
d) Food: include cost for entertainment, house-
hold supplies, cleaning supplies
e) Electricity
f) Heat
g) Water
h) Telephone
i) Laundry/dry cleaning
j) Clothing and shoes
k) Medical/drug expenses not covered by ins.
l) Dental expenses not covered by ins.
m) Insurance (life, health, accident, comprehensive
liability, disability) Exclude
payroll deductions
n) Child care (include babysitting/daycare)
o) Child support payment re: prior marriage
p) School (both child/adult education lessons
q) Entertainment (clubs, social obligations,
travel, vacations, camp, recreation, hobbies)
r) Incidentals (grooming, tobacco, alcohol, gifts,
Xmas, birthday, special occasions, donations)
s) Transportation, auto expense (Gas, oil, repair,
parking, etc.)
t) Auto payments
u) Newspapers, periodicals, books
v) Memberships (Associations, clubs, religious)
w) Care/maintenance of pets
x) Payments for support of dependents not
living at home (not included above)
y) Installment payments/debt payments
z) Other expenses
TOTAL EXPENSES

3. DEBTS AND OBLIGATIONS: Attach schedules if necessary.
Creditor's Name For Original Amount Balance Monthly Pmt.
a)
b)
c)
d)
e)

TOTAL MONTHLY PAYMENTS:
(Apply to Line "y" above.)
4. STATEMENT OF ASSETS:

All property of the parties known to be owned individually or jointly; indicate who holds or how title held: (H) Husband, (W) Wife, (J) Jointly, or (C) for the benefit of the children. Further, if there are any assets owned by either party prior to the marriage or inherited or received as a gift prior to or during the course of the marriage, also identify the asset of assets as follows: (p) prior to the marriage (i) inherited, of (g) gifted. For example, property gifted to husband (g-h) (If insufficient space, insert total and attach schedules)
(a) REAL ESTATE: (If more real estate owned, attach schedule with same information for all additional property)

Type of property:
Address:

Date of Purchase:
Current Market value:
Basis/date of valuation:

Monthly payment:


Original Cost
Cost of Additions:
Total cost:
Mortgage balance:
Other liens:
Equity:
Taxes (19 :
To whom:

(b) PROFIT SHARING/PENSION/RETIREMENT ACCOUNTS
(Include deferred compensation plan, Keogh plan and IRA accounts, employee stock option plans, stock options) Value of interest/amount presently vested
Name:
Name:


(c) LIFE INSURANCE:
Name of Company Policy # Beneficiary Face Amount Net Cash Surrender Value


(d) MEDICAL, CASUALTY, DISABILITY, OTHER INSURANCE. (Describe fully including:
Name of Company Policy No. Group No. Type of Insurance

(e) AUTOMOBILES (Describe fully including:)
Year Make Current Value Amount Lien Net Value

(f) CASH AND DEPOSIT ACCOUNTS (Include all accounts at banks, savings and loans, credit unions, -- savings, checking and certificates of deposit)
Name of Institution Acct/Cert # Type of Acct. Holder Balance Date

(g) STOCKS AND BONDS
No. of Shares Name of Company/Issuer Value Date

(h) BUSINESS INTEREST (Indicate name:)
Name Share Type Business Value less Indebtedness

(i) HOUSEHOLD ITEMS AND PERSONAL EFFECTS.
Description Basis of Valuation Value Date
Household furnishings, furniture, (H)
appliances: (W)

Antiques, heirlooms, china, (H)
silver, furs, objects of art. (W)

Others: Boats, snowmobile, (H)
guns, etc. (W)

(j) OTHER PERSONAL PROPERTY AND ASSETS (specify)

(k) Have you disposed of any assets within the one-year period prior to the filing of the petition for divorce, the proceeds of which are not already accounted for in the above representation of assets?
Yes No

If Yes, describe the asset, the date of transfer, to whom transferred and the value received, if any.

(l) Are you a party in any other law suits? Yes No
If "yes", provide details:

(m) Have you ever filed bankruptcy? Yes No
If "yes", provide details:

Failure by either party to timely file a complete disclosure statement shall authorize the court to accept the statement of the other party as accurate.

I declare, under penalty of perjury that the foregoing, including any attachments, is true and correct and that this declaration was executed on the day of , 20__



Party's Signature