EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA ) Case No. Plaintiff,
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1 vs. EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA Case No. Plaintiff, Dept. No. Defendant. GENERAL FINANCIAL DISCLOSURE FORM The judge uses this form to understand the financial position of the Plaintiff and the Defendant. You must fill this form out completely and truthfully. A. Personal Information: 1. What is your full name? (first, middle, last 2. How old are you? 3. What is your date of birth? 4. What is your occupation? 5. What is your highest level of education? B. Employment Information: (x check one 1. Are you currently employed? q No q Yes If yes, what is the name of your employer? What date were you hired on? (mm/dd/yy 2. Are you disabled? (x check one q No q Yes If yes, what is the level of your disability? What agency certified you disabled? What is the nature of your disability? C. Attorney Information: Complete the following sentences : 1. An Attorney (has/has not been retained on my behalf for this case. 2. As of today, the attorney has been paid a total of on my behalf. 3. I have a credit with my attorney in the amount of. 4. I currently owe my attorney a total of. 5. I owe my prior attorney a total of. Revised 3/4/13
2 Section 1: Personal Income Before you can complete the next section you need to figure out your pay frequency. Your pay frequency is determined by the number of time you are paid each month. Pay Frequency Table 1.00 = Paid one time per month 2.00 = Paid two times per month 2.17 = Paid every two weeks 4.33 = Paid every week A. Fill in the line that applies to you. Only complete line 1 OR line 2. 1 Income Question I am paid an hourly wage in the amount of Earned Number of Hours Worked per Pay Period Pay Frequency (1.00, 2.00, 2.17, or 4.33 x x = $0.00 Monthly Income 2 I am paid a base salary in the amount of x = $0.00 B. Fill in the amount of money you receive each month for the following types of income: Received Income Question Monthly 3 I regularly work overtime and each month earn an average of 4 I receive bonuses, commissions, or tips in the amount of 5 I receive a car, gas, housing, or other allowance in the amount of 6 I receive spousal support in the amount of 7 I receive social security in the amount of 8 I receive social security disability in the amount of 9 I receive workman's compensation benefits in the amount of 10 I receive unemployment benefits in the amount of 11 I receive pension or retirement income in the amount of 12 I receive net rental income in the amount of 13 I receive income from other sources in the amount of 14 Total Income Received (add lines 3-13 $0.00 C. Total monthly income from all sources: 15 Total from Line 1 OR 2 $ Total from Line 14 $ Total Gross Monthly Income (Add lines $0.00
3 Section 2: Personal Deductions A. Fill in the amount of money that is taken out of every paycheck for each of the following deductions: 18 Name of Deduction Court Ordered Child Support is deducted from every paycheck in the amount of Deducted 19 Federal Income Tax is deducted from every paycheck in the amount of 20 Social Security Tax is deducted from every paycheck in the amount of 21 Medicare is deducted from every paycheck in the amount of 22 Union Dues are deducted from every paycheck in the amount of 23 Health Insurance Cost is deducted from every paycheck in the amount of Life, Disability, or Insurance Premiums are deducted from every 24 paycheck in the amount of Federal Health Savings Plan contribution is deducted from every paycheck 25 in the amount of Retirement, Pension, IRA, or 401(k contributions are deducted from every 26 paycheck in the amount of 27 Savings are deducted from every paycheck in the amount of 28 : 29 : 30 Total Paycheck Deductions $ Total Monthly Deductions $0.00 Section 3: Income Summary 32 Total from Line 17 $ Total from Line 30 $0.00 Net Monthly Income $0.00 Section 4: Child Information A. Fill in the table below with the name and date of birth of each of your children, parent the child is living with, and whether the child is from this marriage or relationship:
4 1st 2nd 3rd 4th 5th Child's Name: Child's Date of Birth Whom is child living with? (Mom, Dad, or Both Is this child from this marriage / relationship? (Yes or No B. Fill in the table below with the amount of money you spend each month on the following expenses for the children: Children's Expenses 1st Child 2nd Child 3rd Child 4th Child 5th Child Clothes, Shoes and Accessories Unreimbursed Medical Expenses Telephone and Internet Entertainment 5 Food Insurance (other than health Education Related Expenses Summer Camp/Programs 9 Vehicle 10 Transportation Cost for Visitation Total Monthly Expenses for 11 $0.00 $0.00 $0.00 $0.00 $0.00 Children (add lines 1-11 Section 5: Household Information A. I live with (number other adults, including children over the age of eighteen, who contribute to or pay the household expenses in the amount of $. Section 6: Personal Expenses Fill in the table with the amount of money you spend each month on the following expenses and check whether you pay the expense for you, for the other party, or for both of you.
5 Monthly Expense of Expense Home Mortgage/Rent/Lease Property Taxes HOA Home Owner's Insurance Lawn Care Pest Control Pool Service Security Utilities Water Electric Gas Sewer Home Phone Internet/Cable Medical Health Insurance Unreimbursed Medical Expenses Transportation Car Loan/Lease Payment Fuel Auto Insurance Personal Food (groceries and restaurants Pets Cell phone Membership Fees Clothing, Shoes, etc. Dry Cleaning Debts Credit Card Payments Child Support Alimony/Spousal Support Student Loans Total Monthly Expenses $0.00 For Me For the Party For Both
6 Section 7: Asset and debt Chart Complete the chart below by listed all assets and debts, the value of each, the amount owed on each, and whose name the asset or debt is under (You, the Party, or Both. Description of Asset or Debt Gross Value Owed Net Value Whose Name is on the Account? (Me, the Party or Both 1 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $0.00 Total Value of Assets (add lines 1-20 $0.00 $0.00 $0.00 IMPORTANT: Read the following paragraph carefully. I am the (x check one q Plaintiff / q Defendant in the above action. I swear or affirm under penalty of perjury that I have read and followed all instructions in completing this Financial Disclosure Form. I understand that, by my signature, I guarantee the truthfulness of the information on this Form. I also understand that if I knowingly make false statements I may be subject to punishment, including contempt of court. Your Signature Date
7 CERTIFICATE OF SERVICE I hereby certify that on Monday, February 4, 2013, service of the FINANCIAL DISCLOSURE FORM was made to the following interested parties in the manner set forth below: Via 1 st Class U.S. Mail, postage fully prepaid, to Via Facsimile and/or pursuant to the Consent to Service By Electronic Means on file herein to: And, via 1 st Class U.S. Mail, postage full prepaid, addressed to: Plaintiff Respectfully Submitted, (Signature (Printed Name
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