CAUSE NO: DATED: VERIFIED FINANCIAL DECLARATION OF
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1 STATE OF INDIANA: CIRCUIT COURT: SUPERIOR COURT: MARION COUNTY Petitioner -vs- CAUSE NO: DATED: Respondent VERIFIED FINANCIAL DECLARATION OF Name: Address: Social Security Number: Occupation: Employer: Date of Birth: ATTORNEYS: Megan M. Weddle STOWERS & WEDDLE P.C. 626 N. Illinois Street, Suite 201 Indianapolis, IN GROSS WEEKLY INCOME - ATTACH LAST THREE (3) PAYROLL STUBS AMOUNT 1. Gross Weekly SALARY, WAGES and COMMISSIONS 2. Gross Weekly PENSIONS/RETIREMENT/SOCIAL SECURITY/DISABILITY/EMPLOYMENT/WORKMAN'S COMP 3. Gross Weekly CHILD SUPPORT received from any prior marriage (not this marriage) 4. Gross Weekly DIVIDENDS and INTEREST 5. Gross Weekly RENTS/ROYALTIES less ordinary and necessary expenses (Attach calculation) 6. Gross Weekly BUSINESS/SELF-EMPLOYMENT INCOME less ordinary and necessary expenses (Attach calculation) 7. ALL OTHER SOURCES (Specify)* 8. TOTAL GROSS WEEKLY INCOME (Total of Lines 1 through 7) 9. Minus Weekly COURT ORDERED CHILD SUPPORT for Prior Children - amounts actually paid 10. Minus Weekly LEGAL DUTY CHILD SUPPORT for Prior Children 11. Minus Weekly HEALTH INSURANCE PREMIUMS for Children of This Marriage Only 12. Minus Weekly ALIMONY/SUPPORT/MAINTENANCE Paid to Prior Spouses - amounts actually paid 13. WEEKLY AVAILABLE INCOME (Line 8 less Lines 9 through 12) 14. Weekly WORK RELATED CHILD CARE COSTS for Custodial Parent to work for Children of This Marriage Only 15. Weekly EXTRAORDINARY HEALTHCARE EXPENSES (Children of This Marriage Only - Uninsured Only) 16. Weekly EXTRAORDINARY EDUCATION EXPENSES (Children of This Marriage Only) *Includes Bonuses; Alimony and Maintenance Received from Prior Marriages; Capital Gains; Trust Income; Gifts; Prizes; In-kind Benefits from Employment such as Company Car, Free Housing, Reimbursed Meals. DO NOT include ADC, SSI, General Assistance, Food Stamps. Page 1
2 Names and relationships of all members of household whose expenses are included: Monthly Expenses And Deductions From Income 1. FEDERAL INCOME TAXES (weekly deductions times 4.3) 2. STATE INCOME TAXES (weekly deductions times 4.3) 3. LOCAL INCOME TAXES (weekly deductions times 4.3) 4. SOCIAL SECURITY TAXES (weekly deductions times 4.3) 5. RETIREMENT/PENSION FUND [ Mandatory] [ Optional] (weekly deductions times 4.3) Medicare 6. RENT/MORTGAGE PAYMENTS (Residence) 7. RESIDENCE/PROPERTY TAXES/INSURANCE-if not included in Mortgage Payment (Total for year 12) 8. MAINTENANCE ON RESIDENCE 9. FOOD/HOUSEHOLD SUPPLIES/LAUNDRY/CLEANING 10. ELECTRICITY (Total for year 12) 11. GAS (Total for year 12 or Monthly Budget Amount) 12. WATER/SEWER/SOLID WASTE/TRASH COLLECTION (Total for year 12) 13. TELEPHONE (including Long Distance Charges) Estimate 14. CLOTHING 15. MEDICAL/DENTAL EXPENSES (Not Reimbursed by Insurance) 16. AUTOMOBILE - LOAN PAYMENT 17. AUTOMOBILE - GAS/OIL 18. AUTOMOBILE - REPAIRS 19. AUTOMOBILE - INSURANCE (Total for year 12) 20. LIFE INSURANCE 21. HEALTH INSURANCE (exclude payments for children shown on Page 1, line 11) 22. DISABILITY/ACCIDENT/OTHER INSURANCE (Please specify) 23. ENTERTAINMENT (Clubs, Social Obligations, Travel, Recreation, Cable Television) 24. CHARITABLE/CHURCH CONTRIBUTIONS 25. PERSONAL EXPENSES (Haircuts, cosmetics, grooming, tobacco, alcohol, etc.) 26. BOOKS/MAGAZINES/NEWSPAPERS 27. EDUCATION/SCHOOL EXPENSES (Self and children you have custody of) 28. DAYCARE/WORK RELATED CHILD CARE COSTS (weekly amounts times 4.3) 29. OTHER EXPENSES (Please specify) MONTHLY LOAN/CHARGE CARD EXPENSES FOR BALANCE PAYMENTS Total Monthly Expenses And Deductions From Income (Total of Lines 1 through 38) 40. Average Weekly Expenses And Deductions (Total monthly expenses 4.3) Page 2
3 ASSETS Disclose all assets known to you, even if you do not know the value. Under ownership, H=Husband; W=Wife; J=Joint. Lien amount includes only those debts secured by an item, such as a mortgage against a house, debts shown on title to vehicle, loans against life insurance policies or loans where an item is pledged as collateral. Value assets as of date Petition for Dissolution of Marriage was filed. Show valuation date here: DESCRIPTION GROSS NET TITLE H W J A. HOUSEHOLD FURNISHINGS, FURNITURE, APPLIANCES 1. In possession of Husband 2. In possession of Wife B. AUTOMOBILES, TRUCKS, RECREATIONAL VEHICLES (Include Make, Model and Year) C. SECURITIES - STOCKS, BONDS AND STOCK OPTIONS D. CASH, CHECKING, SAVINGS, DEPOSIT ACCOUNTS, CDs (Include name of Bank/Credit Union and type of account) E. REAL ESTATE (including Land Sales Contracts) 16. Marital Residence (Show Address) Basis of Valuation: Name of lender first mortgage: Name of lender second mortgage: 17. Other (Show Address) Basis of Valuation: Name of lender first mortgage: Name of lender second mortgage: 18. Other (Show Address) Basis of Valuation: Name of lender first mortgage: Name of lender second mortgage: Page 3
4 DESCRIPTION GROSS NET TITLE H W J F. CASH RETIREMENT ACCOUNTS (IRAs, SEPs, KEOUGHS, 401K Employee savings plans, stock ownership/profit sharing plans, etc.) G. RETIREMENT BENEFITS, DEFERRED COMPENSATION PLANS AND PENSIONS (Include information available on benefits, whether benefits are vested or in pay status) SECURITIES - STOCKS, BONDS AND STOCK OPTIONS H. BUSINESS INTERESTS I. LIFE INSURANCE (Show Company Name and Death Benefit) Term and Group _ Whole Life and Others (Show Cash Value under Gross Value) Other (Show Address) _ J. OTHER ASSETS Include any type of assets having value, including jewelry, personal property, assets located in safety deposit boxes, accrued bonuses, etc Page 4
5 ASSETS ACQUIRED BY YOU PRIOR TO THE MARRIAGE OR THROUGH INHERITANCE OR GIFT (Whether now owned or not) SHOW SIGNIFICANT ASSETS ONLY GROSS NET VALUATION DATE A. ASSETS OWNED BY YOU PRIOR TO MARRIAGE (value as of date of marriage) B. ASSETS ACQUIRED BY YOU DURING MARRIAGE THROUGH INHERITANCE OR GIFTS (value as of date of acquisition) I declare under penalty of perjury that the foregoing, including any attachments, is true and correct, that this declaration was executed on the day of, 20. Signature: Printed Name: You are under a duty to supplement or amend this Financial Declaration prior to trial if you learn the information provided is incorrect or the information provided is no longer true. CERTIFICATE OF SERVICE I hereby certify that a true, exact and authentic copy of the foregoing has been served upon the following by United States mail, first class postage prepaid], [ hand delivery] this day of, 20 : Attorney for Megan M. Weddle, STOWERS & WEDDLE P.C. 626 N. Illinois Street, Suite 201 Indianapolis, IN (317) Page 5
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[Appendix V] FAMILY PART CASE INFORMATION STATEMENT
![[Appendix V] FAMILY PART CASE INFORMATION STATEMENT](/thumbs/72/66734849.jpg "[Appendix V] FAMILY PART CASE INFORMATION STATEMENT")
[Appendix V] FAMILY PART CASE INFORMATION STATEMENT Attorney(s): Office Address Tel. No./Fax No. Attorney(s) for: vs. Plaintiff, SUPERIOR COURT OF NEW JERSEY CHANCERY DIVISION, FAMILY PART COUNTY Defendant.
STATE OF ILLINOIS UNITED STATES OF AMERICA COUNTY OF DUPAGE COUNTY IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT
IN RE THE MARRIAGE OF: ) ) Harold J Jones ) CASE NUMBER PETITIONER ) -VS- ) 44-32323 ) Marianne P Jones ) RESPONDENT ) COMPREHENSIVE FINANCIAL STATEMENT PURSUANT TO LOCAL COURT RULE 15.01.3 INSTRUCTIONS
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ENTER YOUR OWN HEADER LINE IN THIS SPACE IN THE CIRCUIT COURT OF THE FIRST JUDICIAL CIRCUIT, IN AND FOR ESCAMBIA COUNTY, FLORIDA Paul A. Sample, Petitioner, and Case No: FA-2012-489 Division: Family Martha
IN THE SUPERIOR COURT OF FULTON COUNTY STATE OF GEORGIA FAMILY DIVISION., ) ) Petitioner, ) ) Civil Action File No. and ) ), ) ) Respondent.
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Complete all highlighted areas of this form. If something does not apply, use N/A. District Court Denver Juvenile Court Pueblo County, Colorado Court Address: 501 N. Elizabeth, Room 116 Pueblo, CO 81003
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David E. Bolger, Attorney at Law
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