STATE OF ILLINOIS UNITED STATES OF AMERICA COUNTY OF DUPAGE COUNTY IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT
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1 IN RE THE MARRIAGE OF: ) ) Harold J Jones ) CASE NUMBER PETITIONER ) -VS- ) ) Marianne P Jones ) RESPONDENT ) COMPREHENSIVE FINANCIAL STATEMENT PURSUANT TO LOCAL COURT RULE INSTRUCTIONS (1) All questions require a written response. If you do not have the information requested or do not know the answer to a particular questions, indicate that as your answer. (2) Use additional sheets if necessary. Petitioner Harold J Jones, being duly sworn, states that the following is an accurate statement as of 11/3/2008, of his/her net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), a statement of income from all sources, a statement of monthly living expenses, a statement of health insurance coverage, and a statement of assets transferred of whatsoever kind and nature and wherever situated: I. General Information Name: Harold J Jones Telephone No: Address: 17 Merion Ln Soc. Sec. No.: Merion, IL Driver's License No.: Date of Birth: 4/5/1970 Date of Marriage: 3/7/1995 Date of Separation: 4/17/2005 Date of Dissolution of Marriage (if applicable): 3/7/1995 Children of this Marriage: Tiffany Birth date 4/5/1998 residing with Marianne Amber Birth date 12/2/2000 residing with Marianne Birth date residing with Birth date residing with Birth date residing with Birth date residing with Current Employer: Address: Self Employment: Address: Other Employment: Address: Check if unemployed Number of Paychecks per year: Other Number of Exemptions Claimed: 3 Number of Dependents: 2 Gross Income from all sources last year: $ Gross income from all sources this year through : $
2 II. STATEMENT OF CURRENT INCOME Gross Monthly Income Salary / Wages / Base Pay $ 14,583 Overtime / Commission $ 0 Cash Bonus $ 667 Stock Bonus $ 0 Draw $ 0 Pension and Retirement Benefits $ 0 Annuity $ 0 Interest Income $ 0 Dividend Income $ 42 Trust Income $ 0 Social Security Payments $ 0 Unemployment Benefits $ 0 Disability Payments $ 0 Worker's Compensation $ 0 Public Aid / Food Stamps $ 0 Investment Income $ 0 Rental Income $ 333 Business Income $ 0 Partnership, Sub-Chapter S, or LLC Income $ 0 Royalty Income $ 0 Fellowships / Stipends $ 0 Other: $ 0 TOTAL MONTHLY GROSS FROM ALL SOURCES $ 15,625 Voluntary deductions from income: Contibutions to IRA / 401k Accounts $ 0 Other Retirement Deductions $ 0 Total Voluntary Deductions $ 0 Required Monthly Deductions: Federal Tax (based on 3 exemptions) $ 0 State Tax (based on 3 exemptions) $ 0 FICA (or Social Security equivalent) $ 0 Medicare Tax $ 0 Mandatory retirement contribution required by law or as condition of employment $ 0 Union Dues (Name of Union: ) $ 0 Health / Hospitalization Premiums $ Prior obligation(s) of support actually paid pursuant to Court order $ 200 Other: $ 0 Total Required Deductions $ 200
3 III. STATEMENT OF CURRENT MONTHLY LIVING EXPENSES 1. Household a. Mortgage or rent (specify): Mortgage $ 200 b. Home equity loan / Second mortgage $ 0 c. Real estate taxes, assessments $ 417 d. Homeowners or renters insurance $ 67 e. Heat / fuel $ 100 f. Electricity $ 75 g. Telephone (including long distance) $ 160 h. Water and Sewer & Refuse removal $ 42 i. Laundry / dry cleaning $ 3 j. Maid / cleaning service $ 325 k. Furniture and appliance repair / replacement $ 100 l. Lawn and garden / snow removal $ 325 m. Food (groceries, liquor, household supplies, etc.) $ 217 o. Other: $ 0 SUBTOTAL HOUSEHOLD EXPENSES: $ 2, Transportation a. Gasoline $ 130 b. Repairs $ 75 c. Insurance / license / city stickers $ 83 d. Payments / replacement $ 500 e. Alternative transportation $ 43 f. Other: Parking $ 43 SUBTOTAL TRANSPORTATION EXPENSES: $ Personal a. Clothing $ 67 b. Grooming $ 9 c. Medical (after insurance proceeds): (1) Doctor $ 0 (2) Dentist $ 0 (3) Optical $ 0 (4) Medication $ 87 d. Insurance: (1) Life Insurance Premiums $ 0 (2) Medical / Hospitalization Insurance Premiums $ 500 (3) Dental /Optical Insurance Premiums $ 0 e. Other: $ 0 SUBTOTAL PERSONAL EXPENSES: $ Miscellaneous: a. Clubs / social obligations / entertainment $ 300 b. Newspapers, magazines, books $ 0 c. Gifts $ 42 d. Donations, church or religious affiliation $ 166 e. Vacations $ 167 f. Other: see attached Schedule A - Other Misc Expense $ 291 SUBTOTAL MISCELLANEOUS EXPENSES: $ 966
4 5. Dependent children: Age Tiffany 10 Amber 7 Children's separate expenses: a. Clothing $ 0 b. Grooming $ 0 c. Education: (1) Tuition $ 0 (2) Books / fees $ 0 (3) Lunches $ 0 (4) Transportation $ 0 (5) Activities $ 0 d. Medical (after insurance proceeds / reimbursement): (1) Doctor $ 0 (2) Dentist $ 0 (3) Optical $ 0 (4) Medication $ 0 e. Allowance $ 0 f. Child care / after school care $ 0 g. Sitters $ 0 h. Lessons and supplies $ 0 i. Clubs / Summer Camps $ 0 j. Vacation $ 0 k. Entertainment $ 0 l. Other: $ 0 SUBTOTAL CHILDREN'S EXPENSES: $ 0 TOTAL MONTHLY LIVING EXPENSES: $ 4,534 RECAP NET MONTHLY INCOME $ 15,425 TOTAL MONTHLY LIVING EXPENSES $ 4,534 DIFFERENCE BETWEEN NET INCOME AND EXPENSES $ 10,891 LESS MONTHLY DEBT SERVICE $ 98 INCOME AVAILABLE PER MONTH $ 10,793
5 IV. STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage? Yes No Name of insurance carrier: Policy or Group No. Type of insurance: Medical Dental Optical Deductible: Per individual: $ Per family: $ Persons covered: Self Spouse Dependents Type of policy: HMO PPO Standard indemnity (i.e. 80/20) Provided by: Employer Private Policy Other Group Monthly cost: Paid by Employer Paid by Employee: $ for dependents per month $ for myself per month V. STATEMENT OF LIABILITIES MONTHLY CREDITOR'S NAME PAYMENT FOR BALANCE DUE PAYMENT MasterCard Bank Two $ 3,456 $ 38 VISA Country Card $ 775 $ 60 CONTINGENT LIABILITIES (Provide name of potential obligor, claiment, basis of claim, date incurred, amount claimed, who incurred.)
6 VI. STATEMENT OF ASSETS - The date of valuation is unless otherwise specified. Description of Asset Title in Name of Date Inheritance(I) Fair Market Acquired Gift (G) Value Cash or Cash Equivalents: 1. Savings or interest bearing accounts. 2. Checking Accounts. 3. Certificates of Deposit. 4. Money Market Accounts. 5. Cash. 6. Other (specify). Investment Accounts and Securities: 1. Stocks 2. Bonds 3. Tax Exempt Securities 4. Secured or Unsecured Notes 5. Other (specify) First Union Joint 1,875 Vanguard Index 500 Joint 12,755 Florida Condo Harold 45,000 Safe Deposit Box: Provide name of bank; description of contents. Real Property: Provide address, type and description, current fair market value, amounts of mortgages, loans or liens. 1. Residence Vacation Home Harold 100,000 Fair Market Value: $100,000 1st Mortgage: $18, Secondary or Vacation Residence 3. Investment or Business Real Estate 4. Vacant Land 5. Other (specify)
7 Motor Vehicle(s), Boats, Trailers, Etc.: Provide year, model, maker, lien, debtor, amount. Business Interests: Type of entity, i.e. Corporations, Partnerships, Sole Proprietorships (Provide percentage interest and number of shares, name of business, type of business.) Insurance Policies: Type of insurance, i.e. Life, Medical Disablity, Business Overhead, Property, etc. Provide name of insurer, policy number, name of insured, owner of policy, face amount, beneficiary, face value, cash surrender value. Retirement, Pension Plans, IRA Accounts, Deferred Compensation, Annuitities, 401k, Profit Sharing, etc.: Provide name and type of plan, trustee of plan, beneficiary, vested or non-vested, most current value. Vanguard IRA Harold 12,555 Stock Options, ESOPS, Other Deferred Compensation or Employment Benefits: (Describe fully) Pending Claims for Personal Injury, Worker's Compensation or other Lawsuits Seeking Monetary Award: Provide date of occurence, nature/amount of claim, date lawsuit filed, case number, name of plaintiffs, name and address of attorney representing you. Collectibles: Coins, stamps, art, antiques, etc. All Other Property: Personal or Real. NOT PREVIOUSLY LISTED, valued in excess of $500.00, exluding normal household furniture and furnishings. Paintings Joint 700 ( 1 ) VII. STATEMENT OF ASSETS TRANSFERRED OR SOLD (List all assets transferred or sold in any manner during the preceding (6) months) Description of Property To Whom Transferred or Sold Date of Transfer Value and Relationship to Transferee Received
8 VIII. NONMARITAL ASSETS: List all nonmarital property claimed by you, identifying each item of property as to the type of property, the date received, the basis on which you claim it is nonmarital property, its location, and the present value of the property: IX. WITNESSES: A. Pursuant to Illinois Supreme Court Rule 213(f), provide the name and address of each witness who will testify at trial and state the subject of each witness' testimony. B. Pursuant to Illinois Supreme Court Title 213(g), provide the name and address of each opinion witness who will offer any testimony: (a) State the subject matter on which the opinion witness is expected to testify: (b) State the conclusion and/or opinions of the opinion witness and the basis therefore, including reports of the witness, if any: (c) State the qualifications of each opinion witness including a curriculum vitae and/or resume, if any: (d) and State the identiy of any written reports of the opinion witness regarding the occurrence: X. PHYSICAL AND MENTAL STATUS: Are you in any manner incapacitated or limited in your ability to earn income at the present time? If so, define and describe such incapacity or limitation, and state when such incapacity or limitation commenced and when it is expected to end.: CERTIFICATE OF DOCUMENT PRODUCTION I, Harold J Jones, certify that the attached corroborating documents are all the documents I have in my possession or that I can obtain upon reasonable effort as of this date. The undersigned certifies that he/she has read the above and foregoing Comprehensive Financial Statement; that he/she knows the contents thereof, and that the information therein contained is true and correct. Signature of Party X Petitioner Respondent Harold J Jones Type or Print Name
9 Footnotes: (1) Paintings have sentimental value to Marianne
10 Petitioner: Harold J Jones Respondent: Marianne P Jones Other Miscellaneous Expenses COMPREHENSIVE FINANCIAL STATEMENT - SCHEDULE A Description Monthly Expense Legal and Accounting Toiletries / Grooming / Drug Store Bank fees Total: 291
Date of Dissolution of Marriage if applicable): Children of this Marriage: Birth date residing with Birth date residing with Birth date residing with
STATE OF ILLINOIS } } ss COUNTY OF DuPAGE } IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT DuPAGE COUNTY, ILLINOIS IN RE THE MARRIAGE OF: } } } Plaintiff, } vs. } Case No. } } Defendant. } COMPREHENSIVE
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