STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS STATEMENT OF ASSETS, LIABILITIES, INCOME AND EXPENSES. vs.

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1 FAMILY COURT, S.C Case # vs. Name: Telephone: Address: City/Town, State: Zip Code: Employer: Occupa@on: City/Town, State: Zip Code: Yes No Single Family Yes No Yes No $ $ TOTAL LIABILITIES (From Page 8) Tot. Monthly Expenses (From Page 5) Name of Insurance Provider: Name of Policy Holder: STATEMENT OF ASSETS, LIABILITIES, INCOME AND EXPENSES A DR6 shall be filed with Complaints for Divorce, Bed & Board Divorce, Miscellaneous Complaints or Child Support Co be filed with Answers or Counterclaims; ModificaVons of Prior [Support] Orders. Employer's Address: If yes, single plan or family plan? Name of Policy Holder: PlainVff Defendant PlainVff's A[orney/Bar Number A[orney's Phone Number Name of Insurance Provider: Employer's Telephone Number: Name of Policy Holder: Do you have a dental plan? Do you have a vision plan? STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DR6 / FI No. of Children Living With You: A[orney's Phone Number Defendant's A[orney/Bar Number 3. TOTAL ASSETS (From Page 7) Tot. Monthly Gross Income (From Page 2) 1. PERSONAL INFORMATION Name of Insurance Provider: 2. DO YOU HAVE HEALTH INSURANCE? DR6 [Revised Oct 2011] 1

2 4. GROSS INCOME FROM ALL SOURCES a) Base Pay from Salary/Wages b) c) PartTime Job d) SelfEmployment (A_ach a Completed Schedule C from your latest tax return) e) Tips f) Commissions g) Bonuses h) Dividends i) Interest j) Trusts k) Annui@es l) Pensions m) Re@rement Funds n) Social Security o) Disability p) Unemployment Insurance q) Worker's Compensa@on r) Public Assistance (welfare, etc.) s) Child Support v) Royal@es and other rights Subtotal: t) Alimony u) Rental from Income Producing Property (A_ach completed Schedule A on Page 9) Weekly BiWeekly Monthly $ $ $ w) Contribu@ons from household members x) Income from SCorps, CCorps, LLCs, etc. y) Capital Gains z) Other Income (Specify below): Other: Other: Other: Total Gross Income: $ $ $ DR6 [Revised Oct 2011] 2

3 5. EXPENSES (pages 3, 4, 5) 1. Housing Rent Mortgage Payment (Principle & Interest) Property Tax Condo Fee Home Maintenance Snow Removal/Lawn Care Other: Total Housing: 2. Oil Wood / Coal / Pellets Propane and Natural Gas Telephone / Cell Phone Electricity Cable Television / Internet Water and Sewer Trash Collec@on Other: Total UVliVes: 3. Insurance Homeowner Renter Vehicle Health / Dental / Vision Life Disability Other: Total Insurance: 4. Uninsured Health Care Expenses Medical Dental Orthodon@cs Eye Care/Glasses/Contact Lenses Prescrip@on Drugs Therapy and Counseling Other: Total Uninsured Health Care Expenses: Weekly BiWeekly Monthly $ $ $ $ $ $ $ $ $ $ $ $ Expenses Con@nued to page 4 DR6 [Revised Oct 2011] 3

4 5. EXPENSES (convnued) 5. Primary Vehicle Payment Other Vehicle Payments Vehicle Maintenance Gas and Oil and Tax Other: Other: Other: Total TransportaVon: 6. General and Personal Expenses Groceries Meals Eaten Out or Taken Out Tobacco/Alcohol Products Clothing and Shoes Hair Care Toiletries and Pet Food and Care Church and Laundry and Dry Cleaning Giks Newspapers and Magazines (personal) Dues and Memberships Entertainment and Other: Total General and Personal Expenses: 7. Children's Expenses and Children's Clothing Diapers Day Care School Supplies School Lunches and Lessons Sports and Camps Other: Total Children's Expenses and AcVviVes: Weekly BiWeekly Monthly $ $ $ $ $ $ $ $ $ Expenses Con@nued to page 5 DR6 [Revised Oct 2011] 4

5 5. EXPENSES (convnued) Weekly BiWeekly Monthly 8. Other Expenses (For example, ungarnished child support or alimony). Specify below. 9. from Paycheck Federal Income Tax number of exemp2ons: State Income Tax number of exemp2ons: Social Security Medicare Local TDI State Union Dues Garnishments 401(k) Other Plans Other: Total Other Expenses: $ $ $ Total DeducVons from Paycheck: $ $ $ 10. Financial Loan Payments Other Debts Savings IRA Other: Total Financial: $ $ $ DR6 [Revised Oct 2011] 5

6 TOTAL EXPENSES: $ $ $ DR6 [Revised Oct 2011] 6

7 6. ASSETS A. Real Estate Primary Residence Address: (street address, city, state, zip) Title Held in Name of: Fair Market Value: Real Estate: Address: (street address, city, state, zip) Title Held in Name of: Fair Market Value: Real Estate: Address: (street address, city, state, zip) Title Held in Name of: Fair Market Value: B. Motor Vehicle: Vehicle 1 Vehicle 2 Vehicle 3 Mortgage Balance: Equity: Mortgage Balance: $ Equity: Mortgage Balance: Equity: Total Real Estate Equity: Year Make Market Value Vehicle Loan C. List IRA, Keough, Pension Profit Sharing, 401k, other Re@rement or Financial Plans, Financial Ins@tu@on or Plan Names: Type Name Total: V D. Annuity Plan(s): Company Name Total: V E. Life Insurance: Present Cash Value Total: Company Death Benefit Cash Total: DR6 [Revised Oct 2011] 7

8 Assets to page 7 DR6 [Revised Oct 2011] 8

9 6. ASSETS (convnued) F.) Savings & Checking Accounts, Money Market Accounts, of Deposit Which are held individually of another person for your benefit, or held by you for the benefit of your minor child(ren): Type V Total: G.) List Mutual Funds, Stocks, Bonds, Savings Bonds, Brokerage Accounts: Firm Type V H.) Financial Claims or Se_lements from Any Source: Descrip@on Total: V I.) Deferred Compensa@on: Descrip@on Total: V J.) Addi@onal Assets: (Ownership Interest in Corpora@on, LLC, Life Estate) Total: Type Name V Total: TOTAL ASSETS: DR6 [Revised Oct 2011] 9

10 7. LIABILITIES (For liabilities attach separate form) Creditor Nature of Debt Date Incurred Amount Due a) b) c) d) e) f) g) h) TOTAL LIABILITIES: $ Total Assets Minus Total LiabiliVes: I cervfy under the pains and penalves of perjury, the informavon stated on the DR6, my financial statemen schedules, if any, is complete, true and accurate. Date Signature NOTARY CERTIFICATION On this day of, 20, before me personally appeared ; he/she is personally known to me and/or he/she proved his/her savsfactory evidence of idenvficavon; he/she executed and acknowledged said instrument to be his/her fre Notary Signature: My Commission Expires: FORM OF IDENTIFICATION: Driver's License / State: State of RI IdenVficaVon Passport Birth CerVficate License Number DR6 [Revised Oct 2011] 10

11 Other ID: Schedule A RENT FROM INCOME PRODUCING PROPERTY (A_ach addi@onal forms for each rental property if necessary.) Gross Annual Rent Received: Property Address: Annual Rental Expenses: Adver@sing: Motor Vehicle and Travel: Insurance: Cleaning and Maintenance: Commissions: Interest on Mortgage to Banks: Other Interest (Specify): : : Legal and Professional Services: Repairs: Supplies: Taxes: U@li@es: Wages: Other Expenses: : : Total Annual Rental Expenses: $ Total Net Annual Rental Income: $ DR6 [Revised Oct 2011] 11

12 Total Net Monthly Rental Income: $ DR6 [Revised Oct 2011] 12

13 INANCIAL STATEMENT omplaints. A DR6 shall DR6 [Revised Oct 2011] 13

14 Annual DR6 [Revised Oct 2011] 14

15 Annual DR6 [Revised Oct 2011] 15

16 Annual DR6 [Revised Oct 2011] 16

17 Annual DR6 [Revised Oct 2011] 17

18 DR6 [Revised Oct 2011] 18

19 Value Value Equity h Value $0.00 DR6 [Revised Oct 2011] 19

20 DR6 [Revised Oct 2011] 20

21 y, jointly, in the name Value $0.00 Value $0.00 Value Value $0.00 Value DR6 [Revised Oct 2011] 21

22 Monthly Payment nt and the a[ached r idenvty through ee act and deed. DR6 [Revised Oct 2011] 22

23 DR6 [Revised Oct 2011] 23

24 DR6 [Revised Oct 2011] 24

FINANCIAL STATEMENT (Long Form)

FINANCIAL STATEMENT (Long Form) INSTRUCTIONS: If your income is less than 75,000.00 annually, you must complete the SHORT FORM financial statement, unless otherwise ordered by the court. I. Plaintiff/Petitioner PERSONAL INFORMATION vs.