Order to Enforce Physical Placement Order

Financial Disclosure Statement

STATE OF WISCONSIN, CIRCUIT COURT, COUNTY

IN RE: THE MARRIAGE OF

Petitioner/Joint Petitioner A:

and

Respondent/Joint Petitioner B:

Financial Disclosure Statement of Petitioner/Joint Petitioner A Respondent/Joint Petitioner B

Case No.

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/Joint Petitioner B 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

Employer Name:

Address:

Address:

City: State: Zip:

Phone: Fax:

Payroll Office: Same as employer

Address:

Address:

City: State: Zip:

Phone: Fax:

3. MEMBERS OF YOUR HOUSEHOLD

I live alone.

List the name and relationship of all people living in your household and whether they help pay expenses.

1. Name: Relationship: Helps pay expenses: Yes No

2. Name: Relationship: Helps pay expenses: Yes No

3. Name: Relationship: Helps pay expenses: Yes No

4. MONTHLY INCOME

Income from wages/salary is received: weekly every other week (bi-weekly) monthly twice a month (semi-monthly)

1. Gross monthly income from salary and wages:

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. Child Support and maintenance received:

8. Rental payments received:

9. Bonuses received:

10. Other sources of income received:

11.

12.

13. Total Gross Income:

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:

27.

28. Total Monthly Deductions:

Monthly Net Income:

5. ANTICIPATED MONTHLY EXPENSES

1. Rent or mortgage payment (primary residence):

2. Real Estate Property taxes:

3. Repairs and maintenance:

4. Food and household supplies:

5. Utilities:

6. Telephone:

7. Cable and Internet Services:

8. Laundry and dry cleaning:

9. Clothing and shoes:

10. Medical, dental and prescription drug expenses:

11. Insurance:

12. Childcare:

13. Child support or spousal support payments:

14. School expenses:

15. Entertainment:

16. Incidentals:

17. Transportation:

18. Auto payments:

19. Auto expenses:

20. Newspapers, magazines, books:

21. Care and maintenance of pets:

22. Payments to dependents not living in your home:

23. Hobbies:

24. Other taxes:

25. Other expenses:

26. Mortgage (other than primary mortgage):

27. Other vehicle payments:

28. Credit card debt:

29. Court ordered obligations:

30. Student loans:

31. Personal loans:

TOTAL MONTHLY EXPENSES:

6. ASSETS

List all assets that you own individually and together with the other party without regard to how they have been or will be divided later.

Household Items

Household furniture & accessories: Ownership Current possession Amount owed Value today

Household appliances:

Automobiles: Year, Make, Model Ownership Current possession Amount owed Value today

Life Insurance

Name of Company & Policy #: Beneficiary: Face Amount: Cash Value Today:

Business Interests

Name of Business & Address: Type of Business: % of Ownership: Value minus indebtedness:

Securities

Name of Company & # of shares: Value today:

Pension, Retirement Accounts, Deferred Compensation, 401K Plans, IRAs, Profit Sharing, etc.

Name of Company & Type of Plan: % Vested: Date of Valuation: Value Today:

Cash and Deposit Accounts

Name of Bank or Financial Institution: Type of Account: Account # last 4 digits: Balance Today:

Other Personal Property

Description of Asset: Type of Property: Value:

Assets Acquired

Description of Asset: Acquired by: A B T G - Gift I - Inherited B - Before Marriage Date Acquired: Value Today:

Real Estate

Parcel 1 Type of Property:

Parcel 1 Address:

Parcel 1 Ownership/Title: A B T

Parcel 1 Current Fair Market Value:

Parcel 1 Current Mortgage Balance:

7. MEDICAL, HOMEOWNERS/RENTERS, AUTOMOBILE, OTHER INSURANCE

What type of insurance policies do you have?

Name of Company, Group # & Policy #: A B T Type of Insurance: Date Issued:

8. DEBTS

List all debts that you owe individually and together with the other party without regard to who will be responsible for payment later.

Creditor’s Name & Address: Type of Obligation: Who Currently Pays: A B T Monthly Payment: Current Balance:

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

Type of filing:

Date of filing:

Current status:

12. DECLARATION

I declare under the penalty of perjury that the above, including all attachments, are complete, true, and correct.