ALL COUNTS CONFERENCE INCOME AND EXPENSE STATEMENT. You must provide your recent tax return and W-2 form at the time of your All Counts Conference.
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1 ALL COUNTS CONFERENCE INCOME AND EXPENSE STATEMENT You must provide your recent tax return and W-2 form at the time of your All Counts Conference. Name Address Telephone Date Social Security Income Employer Address Type of Work Payroll Pay Period (weekly, biweekly, etc.) Gross Pay per pay period ized Payroll Deductions: Federal Withholdings Social Security Local Wage Tax $ State Income Tax Retirement Savings Bonds Credit Union Life Insurance Health Insurance Other (specify) New Pay per pay period Net Pay per pay Period _ GROSS INCOME FROM ALL SOURCES (Fill in Appropriate Column) WEEK MONTH YEAR Interest Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Comp. Worker s Comp Other TOTAL INCOME
2 EXPENSES (Fill in Appropriate Column) WEEK MONTH YEAR HOME: Mortgage/Rent Maintenance ULITILIES: Electric Gas Oil Telephone Water Sewer EMPLOYMENT: Public Transportation Lunch TAXES: Real Estate Personal Property Income INSURANCE: Homeowners Automobile Life Accident Health Other AUTOMOBILE: Payments Fuel Repair MEDICAL: Doctor Dentist Orthodontist Hospital Medicine Special Needs(glasses, braces, orthopedic)
3 WEEK MONTH YEAR EDUCATION: Private School Parochial School College Religious PERSONAL: Clothing Food Barber/Hairdresser Credit Pymts. Credit Cards Charge Accts. Memberships LOANS: Credit Union MISCELLANEOUS: Household help Child care Papers/books/magazines Entertainment Pay TV Vacation Gifts Legal Fees Charitable Contributions Other child support Alimony payments OTHER: TOTAL EXPENSES:
4 ALL COUNTS CONFERENCE INVENTORY AND APPRAISEMENT OF PROPERTY (Plaintiff/Defendant), files the following inventory and appraisement of all property owned or possessed by either party at the time this action was commenced and all property transferred within the preceding three years. (Plaintiff/Defendant) verifies that the statements made in this inventory and appraisement is true and correct. (Plaintiff/Defendant) understands that false statements herein are mad subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. ASSETS OF PARTIES (Plaintiff/Defendant), marks on the list below those items applicable to the case at bar and itemizes the assets of the following pages. IF AN ITEM HAS BEEN APPRAISED, A COPY OF THE APPRAISAL REPORT IS ATTACHED. ( ) 1. Real Property ( ) 2. Motor Vehicles ( ) 3. Stocks, bonds, securities, and options ( ) 4. Certificates of deposit ( ) 5. Checking accounts, cash ( ) 6. Savings accounts, money markets, and savings certificates ( ) 7. Contents of safety deposit boxes ( ) 8. Trusts ( ) 9. Life Insurance policies (Indicate face value, case surrender value, and current beneficiaries) ( ) 10. Annuities ( ) 11. Gifts ( ) 12. Inheritances ( ) 13. Patents, copyrights, inventions, royalties ( ) 14. Personal property outside the home ( ) 15. Business (list all owners, including percentage of ownership, and officer/director positions held by a party with company) ( ) 16. Employment termination benefits severance pay, workers compensation claim/award ( ) 17. Profit sharing plans ( ) 18. Pension plan (indicate employee contribution and date plan vests) ( ) 19. Retirement plans, Individual Retirement Accounts. ( ) 20. Disability payments ( ) 21. Litigation claims (matured and unmatured) ( ) 22. Military/V.A. benefits. ( ) 23. Education benefits ( ) 24. Debts due, including loans, mortgages held ( ) 25. Household furnishings and personalty include as a total category and attach itemized list if Distributed of such asset is in dispute. ( ) 26. Other
5 MARITAL PROPERTY (Plaintiff/Defendant) lists all marital property in which either or both spouse have a legal or equitable interest individually or with other person as of the date of this action was commenced: Description of Property Names of All Owners Cost or Value As of Value As of Appraisal Date Appraisal Date NON-MARITAL PROPERTY (Plaintiff/Defendant) lists all property in which a spouse has a legal or equitable interest which is claimed to be excluded from marital property: Description of Property Names of All Owners Transfer Cost or Value of Value as of Appraisal Date Appraisal Date
6 Basis for Exclusion From Marital Property PROPERTY TRANSFERRED (Plaintiff/Defendant) lists all property in which either or both spouses had a legal or equitable interest individually or with any other person and which has been transferred within the preceding three years. Description Of Property Names of All Owners Transfer Cost or Value As of Net Value As of Net Value As of Transfer Nature of Any Lien At Date Of Transfer Effective Date Of Lien Holder of Lien
7 LIABILITIES OF PARTIES (Plaintiff/Defendant) marks on the list below those items applicable to the case at bar and itemizes the liabilities on the following pages: Secured ( ) 1. Mortgages ( ) 2. Judgments ( ) 3. Liens ( ) 4. Other secured liabilities Unsecured ( ) 5. Credit card balances ( ) 6. Purchases ( ) 7. Loan payments ( ) 8. Notes payable ( ) 9. Other secured liabilities Contingent or Deferred ( ) 10. Contract ( ) 11. Promissory ( ) 12. Lawsuits ( ) 13. Options ( ) 14. Taxes ( ) 15. Other contingent or deferred liabilities LIABILITIES (Plaintiff/Defendant) lists all liabilities of either or both spouses along with or any person as of the date this action was commenced. Description of Liability Names of All Creditors Debtors
8 Date Liability Was Incurred Property Securing The Loan Amount of Liability on Date Incurred and Action Commenced Date Balance Is Due Period Payment and Amount AFFIDAVIT Before me, the undersigned authority appeared, who being duly sworn according to law deposes and says that the facts set forth in the foregoing All Counts Conference forms and attachments, consisting of Page 1 through Page are true and correct to the best of (his/her) knowledge, information, and belief. Sworn to and subscribed before me this day of, 20. Notary Public CERTIFICATE OF SERVICE I hereby certify that the foregoing Addendum A of Plaintiff/Defendant has been served by mailing a true and correct copy hereof to, attorney of record for Plaintiff/Defendant, by first class mail, postage prepaid on this day of, 20. By: Attorney for Plaintiff/Defendant
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