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
PRINT in BLACK ink
For Official Use
Enter the name of the respondent. If joint petitioners, enter the name of the husband.
Enter the case number.
First name Middle name Last name
Petitioner/Joint Petitioner–Wife Respondent/Joint Petitioner– Husband
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
Employer Address Address
City State Zip Phone Fax Payroll Office Same as employer
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|
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)|
|10.||Other sources of income received: (please specify)|
|Total Gross Income (add lines 1–12)|
|14.||Number of tax exemptions claimed|
|15.||Monthly federal income tax withheld|
|16.||Monthly state income tax withheld|
|21.||Union or other dues|
|22.||Retirement or pension fund|
|25.||Child support or spousal support payments|
|26.||Other deductions: (please specify)|
|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)|
|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|
|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|
|China, silver, crystal|
|Recreational vehicles, boats|
|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|
|Real Estate||Parcel 1||Parcel 2||Parcel 3|
|Type of Property|
|Address: street, city, state|
|Current Fair Market Value|
|Current Mortgage Balance|
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.
|Creditor’s Name & Address||Type ofObligation||Who CurrentlyPays||MonthlyPayment||CurrentBalance|
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?
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.
Have you ever filed for bankruptcy? Yes No
If yes, identify the following:
Type of filing
Date of filing
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.
Print or Type Name