Complete all highlighted areas of this form. If something does not apply, use N/A.

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1 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 In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: Willy John Wonka Party who filed case. and Co-Petitioner/Respondent: Mary Jane Wonka Party who was served. Attorney or Party Without Attorney (Name and Address): Willy John Wonka 123 Alphabet Street Pueblo, CO Phone Number: FAX Number: Atty. Reg. #: COURT USE ONLY Case Number: 13DR9000 Division Z Courtroom 311 SWORN FINANCIAL STATEMENT EXAMPLE ONLY COMPLETE FORM AS IT APPLIES TO YOUR SITUATION I, Willy John Wonka (full name) am am not currently employed. (Complete this section if you are employed.) I am employed 40 hours per week. I am paid weekly bi-weekly twice a month monthly. My pay is based on a ly Salary Hourly rate of $ 450 Other: Date employment began 10/15/2003. My occupation is: Carpenter Name of employer: Elmo's Building Blocks Address of employer: 123 Sesame Street (Complete this section if you are Unemployed.) This information is on the Petition. If unemployed, what date did you last work? March 15, 2003 I am unemployed due to disability involuntary layoff at work other: Answer as appropriate. This household consists of 1 adult(s), and 2 minor child(ren). I believe the monthly gross (before taxes) income of the other party is $240. Annual gross (before taxes) income (last tax year 2012) for Petitioner $ 54,00, Co-Petitioner/Respondent $ 28, ly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.) Gross ly Income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, self-employment, business income, other jobs, and monthly reimbursed expenses. $ 450 Social Security Benefits (SSA) SSDI (Disability insurance entitlement program) SSI (supplemental income need based) Unemployment & Veterans Benefits Disability, Workers Compensation Pension & Retirement Benefits 2 Interest & Dividends Public Assistance (TANF) Other - Total ly Income $452 Miscellaneous Income Royalties, Trusts, and Other Investments $ Contributions from Others $ Courts of Colorado Page 1 of 7 R- 10/14 $ 0

2 Dependent Children s monthly gross All other sources, i.e. personal injury income. Source of Income: settlement, non-reported income, etc. Rental Net Income Expense Accounts Child Support from Others Other - Spousal/Partner Support (Maintenance) from Others Other - Total ly Miscellaneous Income $ Total Income $ ly Deductions (Mandatory and Voluntary) Mandatory Deductions Federal Income Tax $ 1 State/Local Income Tax $5.00 PERA/Civil Service Social Security Tax 1 Medicare Tax 5.00 Other - Total Mandatory Deductions $3 Voluntary Deductions Life and Disability Insurance $5.00 Stocks/Bonds $ Health, Dental, Vision Insurance Premium 10 Retirement & Deferred Compensation 3 (401K, IRA) 5 Total number of people covered on Plan Child Care (deducted from salary) 5 Other - Flex Benefit Cafeteria Plan 2 Other - 0 Total Voluntary Deductions $ Total ly Deductions $ ly Expenses Note: List regular monthly expenses below that you pay on an on-going basis and that are not identified in the deductions above. A. Housing 1 st Mortgage $85 2 nd Mortgage $ Insurance (Home/Rental) & Property Condo/Homeowner s/maintenance Taxes (not included in mortgage payment) Fees Rent Other - Total Housing $85 B. Utilities and Miscellaneous Housing Services Gas & Electricity $25 Water, Sewer, Trash Removal $10 Telephone (local, long distance, cellular & pager) 10 Property Care (Lawn, snow removal, cleaning, security system, etc.) Internet Provider, Cable & Satellite TV 15 Other - Total Utilities and Miscellaneous Housing Services $60 C. Food & Supplies Groceries & Supplies $50 Dining Out $100 Total Food & Supplies $60 Courts of Colorado Page 2 of 7

3 D. Health Care Costs (Co-pays, Premiums, etc.) Doctor & Vision Care $3 Dentist and Orthodontist $ Medicine & RX Drugs Therapist Premiums (if not paid by employer) Other - 0 Total Health Care $ E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) Primary Vehicle Payment $ 25 Other Vehicle Payments $ Fuel, Parking, and Maintenance Insurance & Registration/Tax Payments 35 (yearly amount(s) 12) 5 Bus & Commuter Fees Other - Total Transportation $65 F. Children s Expenses and Activities Clothing & Shoes $2 Child Care $10 Extraordinary Expenses i.e. Special Misc. Expenses, i.e. Tutor, Books, Needs, etc. Activities, Fees, Lunch, etc. 10 Tuition Other - Total Children s Expenses and Activities $22 G. Education for you - Please identify status: Full-time student Part-time student Tuition, Books, Supplies, Fees, etc. Other - 0 Total Education $ H. Maintenance (Spousal/Partner Support) & Child Support (that you pay) Maintenance Child Support This family $ This family $60 Other family Other family Total Maintenance and Child Support $60 I. Miscellaneous (Please list on-going expenses not covered in the sections above) Recreation/Entertainment $2 Personal Care (Hair, Nail, Clothing, etc.) $2 Legal/Accounting Fees Subscriptions (Newspapers, Magazines, etc.) 1 Charity/Worship 5 Movie & Video Rentals 1 Vacation/Travel/Hobbies 2 Investments (Not part of payroll deductions) Membership/Clubs 3 Home Furnishings Pets/Pet Care 2 Sports Events/Participation Other - Other - Other - Other - Total Miscellaneous $ Courts of Colorado Page 3 of 7

4 Total ly Expenses (Totals from A I) $ Debts (unsecured) List unsecured debts such as credit cards, store charge accounts, loans from family members, back taxes owed to the I.R.S., etc. Do not list debts that are liens against your property, such as mortgages and car loans, because that payment is already listed as an expense above, and the total of the debt is shown elsewhere as a deduction from value where that asset is listed, such as under Real Estate or Motor Vehicles. For name on account, "P" = Petitioner, "C/R = Co-Petitioner or Respondent, "J" = Joint. Name of Creditor Account Number (last 4- digits only) P C/R J Date of Balance Balance Minimum ly Payment Required Reason for Which Debt Was Incurred Jo Johnson Hardware /01/13 $200 $2 Work Tools Kohl s /01/ Christmas Total unsecured Debt balance and minimum monthly payment. $350 $35.00 Total Minimum ly Payment SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES) Total Income (from Page 1) $ 452 A Total ly Deductions (from Page 2) $ B Total ly Net Income (A minus B) $ Total ly Expenses (from Page 3) Total Minimum ly Payment Required - Debts Unsecured (from Page 4) $ C $ D Total ly Expenses and Payments (C plus D) $ Net Excess or Shortfall (ly Net Income less ly Expenses and Payments) (+/-) $ You must calculate this page by selecting data from pages 1-4 and placing in the appropriate location above. Courts of Colorado Page 4 of 7

5 5. Assets You MUST disclose (reveal) all assets correctly. By indicating, you are stating affirmatively (true and correct) that you or the other party, do not have assets in that category. Please attach additional copies of pages 5 & 6 to identify your assets, if necessary. If the parties are married, check under the heading Joint (J) all assets acquired (bought or obtained) during the marriage but not by gift or inheritance. Under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R), check assets owned before this marriage and assets acquired by gift or inheritance. If the parties were NEVER married to each other or are using this form to modify child support, list all of each party s assets under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R). "P" = Petitioner, "C/R = Co-Petitioner or Respondent, "J" = Joint. A. Real Estate (Address or Property Description and Name of Creditor/ Lender) P C/R J Estimated Value as of Today. Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed) 123 Alphabet Street, Pueblo CO $17500 $12500 $5000 Total $17500 $12500 $5000 B. Motor Vehicles & Recreation Vehicles Including Motorcycles, ATV s, Boats, etc.) (Year, Make, Model) (Name of Creditor/Lender) P C/R J Estimated Value as of Today. Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed) 2011 Ford F-150 4x Toyota Camry Total $2500 $1000 $1500 C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution) P C/R J Type of Account Account # (last 4-digits only) Balance as of Today Best Bank of America Savings 5555 $450 Best Bank of America Checking Total $670 D. Life Insurance (Name of Company/Beneficiary) P C/R J Type of Policy Face Amount of Policy Cash Value today Super Life Insurance Company Whole Life $10000 $10000 Elmo's Building Blocks Whole Life US Banking Services Whole Life Total $15000 $15000 Courts of Colorado Page 5 of 7

6 E. Furniture, Household Goods, and Other Personal Property, i.e. Jewelry, Antiques, Collectibles, Artwork, Power Tools, etc. Identify Items and report in total. P C/R J Current Possession Held by Estimated P C/R J Value as of Today. Value = what you could sell it for in its current condition. All household furniture and appliances $1000 Power tools, hand tools, shop equipment 1000 Lawn Mower, Lawn & Garden Tools 100 Riding Lawn Mower 250 Total $2350 F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts If owned please attach JDF 1111-SS. Total $ G. Pension, Profit Sharing, or Retirement Funds If owned please attach JDF 1111-SS. Total $5000 H. Miscellaneous Assets If you own any of the assets identified below, please check the appropriate box and attach JDF 1111-SS to report the value. Business Interests Stock Options Money/Loans owed to you IRS Refunds due to you Country Club & Other Memberships Livestock, Crops, Farm Equipment Pending lawsuit or claim by you Accrued Paid Leave (sick, vacation, personal) Oil and Gas Rights Vacation Club Points Safety Deposit Box/Vault Trust Beneficiary Frequent Flyer Miles Education Accounts Health Savings Accounts Mineral and Water Rights Other - Other - Other - Other - Total $ I. Separate Property If owned please attach JDF 1111-SS to identify the property and to report the value. Total $ Total Value/Balance of All Assets (A I) $29520 Include the total of all assets here. Courts of Colorado Page 6 of 7

7 By signing this form, you state that you have read and understand the statements below. I swear or affirm under oath (promise of truth) that this Sworn Financial Statement, attached schedules, and mandatory disclosures contain a complete disclosure of my income, expenses, assets, and debt as of the date of my signature. I understand that if the information I have provided changes or needs to be updated before a final decree or order is issued by the Court, that I have a duty to provide the correct or updated information. I understand that this oath is made under penalty of perjury (consequences for false information). I understand that if I have omitted (left out) or misstated any material information, intentionally or not, the Court will have the power to enter orders to address those matters, including the power to punish me for any statements made with the intent to defraud or mislead the Court or the other party. Date: 12/05/13 Sign this form in the presence of a Notary Public or a Court Clerk. Willy John Wonka Signature of Petitioner or Co-Petitioner/Respondent Mark the appropriate box above based on who you are in this case. Subscribed and affirmed, or sworn to before me in the County of, State of, this day of, 20. My Commission Expires: Notary Public/Deputy Clerk CERTIFICATE OF SERVICE To be completed if the Sworn Financial Statement is not being filed with JDF Certificate of Compliance with Mandatory Financial Disclosures I certify that on 12/05/13 (date) a true and accurate copy of the SWORN FINANCIAL STATEMENT was served on the other party by: Hand Delivery, E-filed, Faxed to this number:, or By placing it in the United States mail, postage pre-paid, and addressed to the following: To: Mary Jane wonka 456 Right Street Pueblo, CO Check the box that describes how and when you served a copy of this form on the other party. Willy John Wonka Your signature Courts of Colorado Page 7 of 7

Complete all highlighted areas of this form. If something does not apply, use N/A.

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