Fill and Sign the Disclosure Statement Form

PRINT in BLACK ink Enter the name of the county in which this case is filed. STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Enter the name of the petitioner. If joint petitioners, enter the name of the wife. In RE: The marriage of: Petitioner/Joint Petitioner-Wife:       First name Middle name Last name andOn the far right, check Petitioner/Joint Petitioner- Wife or Respondent/Joint Petitioner-Husband Financial Disclosure Statement of: Petitioner/Joint Petitioner-Wife Respondent/Joint Petitioner- Husband Case No.       Enter the name of the respondent. If joint petitioners, enter the name of the husband. Respondent/Joint Petitioner-Husband:       First name Middle name Last name Enter the case number. This form must be filed with the court within the time period set by the court but no later than 90 DAYS after the service of the Summons and Petition on the respondent (spouse) or the filing of a Joint Petition . Failure by either party to complete and file this form or attachments as required will authorize the court to accept the statement of the other party as the basis for its decisions. Deliberate failure to provide complete disclosure is perjury. 1. PROOF OF INCOME  Attach a statement reflecting income earned to date for the current year.  Attach most recent W-2 Statement. 2. GENERAL INFORMATION Name       Address       Address       City       State       Zip       Phone (day)       Phone (evening)       Alternative Phone:       Social Security Number       Occupation       Employer       Address       Address       City       State       Zip       Phone       Fax       Payroll Office Same as employer Address       Address       City       State       Zip       Phone       Fax       FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 8 Financial Disclosure Statement Page 2 of 8 Case No. ____________ 3. MEMBERS OF YOUR HOUSEHOLD Enter the name and relationship of all people living in your household. Check yes or no to identify if they contribute to payment of household expenses. Name I live alone Relationship This person helps pay expenses Yes No 1.             2.             3.             4.             5.             6.             7.             8.             4. MONTHLY INCOME Income from wages / salary is received (check one): To calculate monthly gross income use the multiplier shown: weekly -multiply weekly income by 4.3 every other week (bi-weekly) - multiply bi-weekly income by 2.15 monthly twice a month- multiply semi-monthly income by 2 MONTHLY GROSS INCOME 1. 1. Gross monthly income (before taxes and deductions) from salary and wages, including commissions, allowances and overtime. (See above how to calculate.)       2. Pensions and retirement funds received       3. Social Security benefits received       4. Disability and Unemployment Insurance received       5. Public Assistance Funds received       6. Interest and Dividends received       7. 7. Child Support and maintenance (spousal support) received from any prior marriage/relationship       8. Rental payments received (from property you rent to others)       9. Bonuses received       10. Other sources of income received: (please specify)       11.             12.             13 . Total Gross Income (add lines 1-12)       MONTHLY DEDUCTIONS 14. Number of tax exemptions claimed       15. Monthly federal income tax withheld       16. Monthly state income tax withheld       17. Social Security       18. Medicare       19. Medical insurance       20. Other insurances       21. Union or other dues       22. Retirement or pension fund       23. Savings plan       24. Credit union       25. Child support or spousal support payments       26. Other deductions: (please specify)             27.             28. Total Monthly Deductions (add lines 14 – 27)       MONTHLY NET INCOME (subtract line 28 from line 13)       FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 8 Financial Disclosure Statement Page 3 of 8 Case No. ____________ 5. ANTICIPATED MONTHLY EXPENSES My Monthly Expenses 1. Rent or mortgage payment (primary residence)       2. Real Estate Property taxes (residence)       3. Repairs and maintenance (including maintenance of appliances and furnishings)       4. Food (include eating out) and household supplies       5. Utilities (electricity, heat, water, sewage, trash)       6. Telephone (local, long distance & cellular)       7. Cable and Internet Services       8. Laundry and dry cleaning       9. Clothing and shoes       10. Medical, dental and prescription drug expenses (not covered by insurance)       11. Insurance (life, health, accident, auto, liability, disability, homeowner’s or renter’s- excluding insurance that is paid through payroll deductions)       12. Childcare (babysitting and day care)       13. Child support or spousal support payments (due to previous marriage or relationship) (Exclude payments made through payroll deductions)       14. School expenses (child and adult education)       15. Entertainment (include clubs, social obligations, travel, recreation)       16. Incidentals (grooming, tobacco, alcohol, gifts, holidays and special occasions)       17. Transportation (other than automobile)       18. Auto payments (loans/leases)       19. Auto expenses (gas, oil, repairs, maintenance)       20. Newspapers, magazines, books       21. Care and maintenance of pets (food, vet, grooming)       22. Payments to any dependents not living in your home and not included in a category above (including college age children)       23. Hobbies       24. Other taxes than those listed above (exclude payroll deductions)       25. Other expenses (include expenses of other real properties owned, professional services such as counseling and tax/legal advice, etc)       Other Monthly installment payments:       26. Mortgage (other than primary mortgage)       27. Other vehicle payments       28. Credit card debt (total minimum monthly payments)       29. Court ordered obligations       30. Student loans       31. Personal loans             TOTAL MONTHLY EXPENSES (Add lines 1-31)       FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 8 Financial Disclosure Statement Page 4 of 8 Case No. ____________ 6. ASSETS: List ALL assets that you own individually and together with your spouse without regard to how they have been or will be divided later. If you do not have assets in an asset category, write “none” under the heading and enter “zero” in the estimated value column. If you need more space, please attach additional sheets. W = Wife H= Husband B= Both Ownership or Title Held by Current Possession Household Items W H B W H B Amount Owed Estimated Value Today Household furniture & accessories             Household appliances             Kitchen equipment             China, silver, crystal             Jewelry             Clothing             Antiques             Art             Electronic equipment             Sports equipment             Recreational vehicles, boats             Tools             Other             Automobiles: Year, Make, Model Amount Owed Estimated Value Today                                                                                           FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 8 Financial Disclosure Statement Page 5 of 8 Case No. ____________ Securities: Stocks, Bonds, Mutual Funds, Commodity Accounts Name of Company & # of shares Ownership or Title held by W = Wife H= Husband B= Both Value Today W H B                                                                                     Life Insurance Name of Company & Policy # Beneficiary Face Amount Cash Value Today                                                                                                 Cash and Deposit (Savings and Checking) Accounts Name of Bank or Financial Institution Type of Account Account # Last 4 digits Balance Today                                                                                                                         Pension, Retirement Accounts, Deferred Compensation, 401K Plans, IRAs, Profit Sharing, etc. Name of Company & Type of Plan % Vested if known Date of Valuation Value Today                                                                                                                         FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 8 Financial Disclosure Statement Page 6 of 8 Case No. ____________ Business Interests Name of Business & Address W H B Type of Business % of Ownership Value MINUS Indebtedness                                                                                                 Other Personal Property Description of Asset Type of Property Value                                                                                           Assets Acquired Description of Asset G - Gift I - Inherited B - Before Marriage Ownership Acquired by Date Acquired Value Today W H B G I B                                                                                           Real Estate Parcel 1 Parcel 2 Parcel 3 Type of Property                   Address: street, city, state                   Current Fair Market Value                   Current Mortgage Balance                   Other Liens                                                                   FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 6 of 8 Financial Disclosure Statement Page 7 of 8 Case No. ____________ 7. MEDICAL, HOMEOWNERS/RENTERS, AUTOMOBILE, OTHER INSURANCE What type of insurance policies do you have? Name of Company, Group # & Policy # W H B Type of Insurance Date Issued                                                                                           8. DEBTS: List ALL debts that you owe individually and together with your spouse without regard to who will be responsible for payment later. If there are additional DEBTS, please attach a separate sheet of paper with the creditor’s name and address, the type of obligation, who pays (W, H, B) and the current balance. Creditor’s Name & Address Type of Obligation Who Currently Pays Monthly Payment Current Balance W H B                                                                                                                                                                                                                                                                                                                                                 FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 7 of 8 Financial Disclosure Statement Page 8 of 8 Case No. ____________ 9. DISPOSAL OF ASSETS Did you dispose of any assets (sold, given away, or destroyed) in the 12 months before the case was filed? Yes No If yes, complete chart below: Property / Asset Date of Disposal Fair Market Value on Date of Disposal                                                                         10. CURRENT LITIGATION Are you a party in any other lawsuit or litigation? Yes No If yes, identify the lawsuit or litigation.       11. BANKRUPTCY Have you ever filed for bankruptcy? Yes No If yes , identify the following: Type of filing       Date of filing       Current status       12. DECLARATION I declare under the penalty of perjury that the above, including all attachments, is true and correct as of the date signed below. Sign and print your name. Enter the date on which you signed your name. Note: This signature does not need to be notarized. Signature       Print or Type Name       Date FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 8 of 8