Wisconsin Financial Disclosure Statement Form

Financial Disclosure Statement.pdf This form allows for either party to submit proof of their income and let the court, as well as their spouse, know of past and future income to figure out the child

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Financial Disclosure

Statement of:

 

 

Enter the name of the respondent. If joint petitioners, enter the name of the husband.

Enter the case number.

 

Respondent/Joint PetitionerHusband:

 

 

 

First name Middle name Last name

Petitioner/Joint PetitionerWife Respondent/Joint Petitioner– Husband

 

 

 

 

Case No.

 

 

This form must be filed with the court within the time period set by the court but no later than 90 DAYS after the service of the Summons and Petition on the respondent (spouse) or the filing of a Joint Petition. Failure by either party to complete and file this form or attachments as required will authorize the court to accept the statement of the other party as the basis for its decisions. Deliberate failure to provide complete disclosure is perjury.

 

1. PROOF OF INCOME

Attach a statement reflecting income earned to date for the current year. Attach most recent W-2 Statement.

 

2. GENERAL INFORMATION

 

Name Address Address

City                                                                                          State                                           Zip                                  Phone (day)                                                                            Phone (evening)                                                                 Alternative Phone:                                                                     Social Security Number

Occupation

 

Employer Address Address

City                                                                                          State                                           Zip                                  Phone                                                                                        Fax                                                                                     Payroll Office                    Same as employer

Address

Address

City State  Zip   Phone Fax

Financial Disclosure Statement Page 2 of 8 Case No.

3. MEMBERS OF YOUR HOUSEHOLD

Enter the name and relationship of all people living in your household. Check yes or no to identify if they contribute to payment of household expenses.

NameI live alone Relationship This person helps payexpensesYes No
1.
2.
3.
4.
5.
6.
7.
8.

 

4. MONTHLY INCOME

Income from wages / salary is received (check one):

To calculate monthly gross income use the multiplier shown:

weekly -multiply weekly income by 4.3 every other week (bi-weekly) -multiply bi-weekly income by 2.15 monthly twice a month-multiply semi-monthly income by 2

MONTHLY GROSS INCOME
1. 1. Gross monthly income (before taxes and deductions) from salary and wages,including commissions, allowances and overtime. (See above how to calculate.)
2. Pensions and retirement funds received
3. Social Security benefits received
4. Disability and Unemployment Insurance received
5. Public Assistance Funds received
6. Interest and Dividends received
7. 7. Child Support and maintenance (spousal support) received from any priormarriage/relationship
8. Rental payments received (from property you rent to others)
9. Bonuses received
10. Other sources of income received: (please specify)
11.
12.
Total Gross Income (add lines 112)
MONTHLY DEDUCTIONS
14. Number of tax exemptions claimed
15. Monthly federal income tax withheld
16. Monthly state income tax withheld
17. Social Security
18. Medicare
19. Medical insurance
20. Other insurances
21. Union or other dues
22. Retirement or pension fund
23. Savings plan
24. Credit union
25. Child support or spousal support payments
26. Other deductions: (please specify)
27.
28. Total Monthly Deductions (add lines 14 27)
MONTHLY NET INCOME (subtract line 28 from line 13

Financial Disclosure Statement Page 3 of 8 Case No.

 

 

 

 

5. ANTICIPATED MONTHLY EXPENSES

 

My Monthly Expenses
1. Rent or mortgage payment (primary residence)
2. Real Estate Property taxes (residence)
3. Repairs and maintenance (including maintenance of appliances and furnishings)
4. Food (include eating out) and household supplies
5. Utilities (electricity, heat, water, sewage, trash)
6. Telephone (local, long distance & cellular)
7. Cable and Internet Services
8. Laundry and dry cleaning
9. Clothing and shoes
10. Medical, dental and prescription drug expenses (not covered by insurance)
11. Insurance (life, health, accident, auto, liability, disability, homeowner’s or renter’s- excluding insurance that is paid through payroll deductions)
12. Childcare (babysitting and day care)
13. Child support or spousal support payments (due to previous marriage or relationship) (Exclude payments made through payroll deductions)
14. School expenses (child and adult education)
15. Entertainment (include clubs, social obligations, travel, recreation)
16. Incidentals (grooming, tobacco, alcohol, gifts, holidays and special occasions)
17. Transportation (other than automobile)
18. Auto payments (loans/leases)
19. Auto expenses (gas, oil, repairs, maintenance)
20. Newspapers, magazines, books
21. Care and maintenance of pets (food, vet, grooming)
22. Payments to any dependents not living in your home and not included in a category above (including college age children)
23. Hobbies
24. Other taxes than those listed above (exclude payroll deductions)
25. Other expenses (include expenses of other real properties owned, professional services such as counseling and tax/legal advice, etc)
Other Monthly installment payments:
26. Mortgage (other than primary mortgage)
27. Other vehicle payments
28. Credit card debt (total minimum monthly payments)
29. Court ordered obligations
30. Student loans
31. Personal loans
TOTAL MONTHLY EXPENSES (Add lines 1-31)

 

 

 

 

 

Financial Disclosure Statement Page 4 of 8 Case No.

 

6. ASSETS: List ALL assets that you own individually and together with your spouse without regard to how they have been or will be divided later.

 

If you do not have assets in an asset category, write “none” under the heading and enter “zero in the estimated value column. If you need more space, please attach additional sheets.

 

W = Wife H=HusbandB=Both
Ownership orTitle Held by CurrentPossession
Household Items W H B W H B Amount Owed Estimated Value Today
Household furniture & accessories
Household appliances
Kitchen equipment
China, silver, crystal
Jewelry
Clothing
Antiques
Art
Electronic equipment
Sports equipment
Recreational vehicles, boats
Tools
Other
Automobiles:Year, Make, Model Amount Owed Estimated Value Today

Financial Disclosure Statement Page 5 of 8 Case No.

 

Securities: Stocks, Bonds, Mutual Funds, Commodity Accounts Name of Company & # of shares Ownership or Title held byW = Wife H=HusbandB=Both ValueToday
W H B
Life InsuranceName of Company & Policy # Beneficiary Face Amount Cash ValueToday
Cash and Deposit (Savings andChecking) AccountsName of Bank or Financial Institution Type ofAccount Account #Last 4 digits BalanceToday
Pension, Retirement Accounts, Deferred Compensation, 401K Plans, IRAs, Profit Sharing, etc. Name of Company & Type of Plan % Vestedif known Date of Valuation ValueToday

Financial Disclosure Statement Page 6 of 8 Case No.

 

 

 

Business InterestsName of Business & Address W H B Type ofBusiness % of Ownership Value MINUS Indebtedness
Other Personal PropertyDescription of Asset Type ofProperty Value
Assets Acquired Description of Asset G GiftI – InheritedB – Before Marriage Ownership Acquired by Date Acquired Value Today
W H B G I B
Real Estate Parcel 1 Parcel 2 Parcel 3
Type of Property
Address: street, city, state
Current Fair Market Value
Current Mortgage Balance
Other Liens

Financial Disclosure Statement Page 7 of 8 Case No.

 

 

7. MEDICAL, HOMEOWNERS/RENTERS, AUTOMOBILE, OTHER INSURANCE

What type of insurance policies do you have?
Name of Company, Group # & Policy # W H B Type ofInsurance Date Issued

 

 

8. DEBTS: List ALL debts that you owe individually and together with your spouse without regard to who will be responsible for payment later.

 

If there are additional DEBTS, please attach a separate sheet of paper with the creditor’s name and address, the type of obligation, who pays (W, H, B) and the current balance.

Creditors Name & Address Type ofObligation Who CurrentlyPays MonthlyPayment CurrentBalance
W H B

Financial Disclosure Statement Page 8 of 8 Case No.

 

 

9. DISPOSAL OF ASSETS

Did you dispose of any assets (sold, given away, or destroyed) in the 12 months before the case was filed?

Yes No

If yes, complete chart below:

 

10. CURRENT LITIGATION

 

Are you a party in any other lawsuit or litigation? Yes No

 

If yes, identify the lawsuit or litigation.

 

 

 

 

11. BANKRUPTCY

 

Have you ever filed for bankruptcy? Yes No

 

If yes, identify the following:

 

Type of filing

 

Date of filing

 

Current status

 

12. DECLARATION

 

I declare under the penalty of perjury that the above, including all attachments, is true and correct as of the date signed below.

 

 

 

Sign and print your name.

 

 

 

Enter the date on which you signed your name.

 

Note: This signature does not need to be notarized.

Signature

 

 

Print or Type Name

 

 

Date