Fill and Sign the In Re the Marriage of Petitioner and Respon Form

IN RE THE MARRIAGE OF: _____ ___________________________________ PETITIONER and _____ ___________________________________ RESPONDENT q Petitioner q Res pondent submits under oath the following Verified Disclosure Statement pursuant to FCRPP 2 OR FCRPP 3, which requires full and prompt disclosure of the following information: NOTE: A response of “see attached” is not appropriate for any portion of this statement. Attach documents requested herein only. I. IDENTIFYING INFORMATION OF BOTH PARTIES Petitioner Respondent Name: _______________________________________ Name: ______________________________________ Street Address: ________________________________ Street Address: _______________________________ City, State, Zip: ________________________________ City, State, Zip: _______________________________ Age: ____ Ph one #: _________________________ Age: ____ Phone #: ___________________________ II. INCO ME AND EMPLOYMENT INFORMATION OF BOTH PARTIES (If self-employed name of company and adjusted gross monthly income) Petitioner Respondent Employer Name: _______________________________ Employer Name: ______________________________ Gross monthly income: $ ________________________ Gross monthly income: $ ________________________ Other income: $ ___ ____________________________ Other income: $ _______________________________ III. MARRIAGE INFORMATION Date of Marriage: ______________________________ Date of separation: _____________________________ Place of Marriage (city, county & state): _______________________________________________________________ q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Page 1 of 10 Commonwealth of KentuckyCourt of Justice www.courts.ky.gov FCRPP 2 and FCRPP 3 q Preliminary Verified Disclosure Statement* q Final Verified Disclosure Statement* lex et justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE Case No. ____________________ Court ____________________ County ____________________ Division ____________________ q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 2 of 10 Case No. _________________________________________ IV. CHILDREN’S INFORMATION (If more than 3 children, continue on a separate sheet) A. Minor children born to parties (number ________) q More CHILDREN attached? Name Current Age B. Monthly child care/day care expenses: Cost $ ________________ Paid by ________________ C. Monthly medical, dental and vision insurance for children: Cost $ ________________ Paid by ________________ D. Either party court-ordered to pay child support for a child born before the children born of this marriage? q Yes q No Paying party _____________________________________________ Amount: $ ____________________________ Children: ( List names and ages ) _____________________________________________________________________ _______________________________________ ________________________________________________________ V. SUMMARY OF ASSETS & DEBTS A. REAL ESTATE (If more than 2 properties, continue on a separate sheet) Are you making a non-marital claim? q Ye s q No If yes, you must comply with Section IX below. Property 1: Address: ______________________________________________________________\ _________________________ 1st Mortgage Company: ___________________________________________________________________________ 1st Mortgage Payoff Amount: ________________________ 2nd Mortgage Company or Home Equity Loan: _________________________________________________________ 2nd Mortgage or Home Equity Loan Payoff Amount: ______________________________ Fair Market Value: _________________ Valuation Date: __________________ Equity: ____________________ More REAL ESTATE attached? q Yes q No Total Real Estate Equity: ___________________________ Property 2: Address: ______________________________________________________________\ _________________________ 1st Mortgage Company: ___________________________________________________________________________ 1st Mortgage Payoff Amount: ________________________ 2nd Mortgage Company or Home Equity Loan: _________________________________________________________ 2nd Mortgage or Home Equity Loan Payoff Amount: ______________________________ Fair Market Value: _________________ Valuation Date: __________________ Equity: ____________________ q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 3 of 10 Case No. _________________________________________ C. BANK ACCOUNTS – Checking, Savings, CDs, Money Market accounts, etc. (If more than 3 accounts, continue on a separate sheet) (Do not list account numbers) Are you makin g a non -marital claim? q Yes q No If yes, you must comply with Section IX below. Owner(s) Institution Name Type of Account Valuation Date Balance [ NO ACCOUNT NUMBE RS] More BANK ACCOUNTS attached? q Yes q No Total Current Balances: B. VEHICLES - Automobiles, Motorcycles, Boats, Trucks, Motor Homes, etc. (If more than 3 vehicles, continue on a separate sheet) Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below. Primary Driver: __________________________ Year, Make & Model: ______________________________________ NADA Value: _______________ Valuation Date: _______________ Debt Owed: ________________ Lien Holder: _____________________________________________________________ Equity: ________________ Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment: ________________ Lease Term Ends: ___________ _____ More VEHICLES attached? q Yes q No Total Vehicle Equity: ___________________________ D. STOCKS, BONDS, PORTFOLIOS, MUTUAL FUNDS, ETC. (If more than 3, continue on a separate sheet) Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below. Institution Name Stock/Portfolio Name V aluation Date Current Value More INVESTMENTS attached? q Yes q No Total Current Values: Vehicle 1: Vehicle 2: Vehicle 3: Primary Driver: __________________________ Year, Make & Model: ______________________________________ NADA Value: _______________ Valuation Date: _______________ Debt Owed: ________________ Lien Holder: _____________________________________________________________ Equity: ________________ Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment: ________________ Lease Term Ends: ___________ _____ Primary Driver: __________________________ Year, Make & Model: ______________________________________ NADA Value: _______________ Valuation Date: _______________ Debt Owed: ________________ Lien Holder: _____________________________________________________________ Equity: ________________ Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment: ________________ Lease Term Ends: ___________ _____ q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 4 of 10 Case No. _________________________________________ E. RETIREMENT BENEFITS – IRA, Keogh, 401(K), 403(b), Pension, etc. (If more than 3, continue on a separate sheet) Are you making a non -marital claim? q Yes q No If yes, you must comply with Section IX below. Participant Plan Name Contrib/Non V ested/Non Pay Status? Valuation Date Balance More RETIREMENT BENEFITS attached? q Yes q No Total Retirement Benefits Values: Have any loans been taken out against any of these Retirement Benefits? q Yes q No If so, describe: ___________________________________________________________________________________ F. LIFE INSURANCE (If more than 3 policies, continue on a separate sheet) Are you making a non-ma rital claim ? q Yes q No If yes, you must comply with Section IX below. G. BUSINESS INTERESTS (If more than 3 businesses, continue on a separate sheet) Are you making a non-ma rital claim? q Yes q No If yes, you must comply with Section IX below. Name of Business & Owner: ________________________________________________________________________ Percentage of Ownership: ___________ Type of Business: __________________________________________ Corporation, Sole Proprietorship, Partnership, Etc.: ______________________________________________________ Valuation Date: _______________ Business Loan(s) Balance: _______________ Value of Interest: ______________ Company: ____________________________________________ Party Insured: ____________________________ Beneficiary: ___________________________________________________________ Term/Whole: ______________ Policy #: ________________ ________ Valuation Date: ____________ Cash Surrender Value: ___________________ Policy 1: Company: ____________________________________________ Party Insured: ____________________________ Beneficiary: ___________________________________________________________ Term/Whole: ______________ Policy #: ________________ ________ Valuation Date: ____________ Cash Surrender Value: ___________________ Policy 2: Company: ____________________________________________ Party Insured: ____________________________ Beneficiary: ___________________________________________________________ Term/Whole: ______________ Policy #: ________________ ________ Valuation Date: ____________ Cash Surrender Value: ___________________ Policy 3: More LIFE INSURANCE attached? q Ye s q No Total Cash Value : ___________________________ Name of Business & Owner: ________________________________________________________________________ Percentage of Ownership: ___________ Type of Business: __________________________________________ Corporation, Sole Proprietorship, Partnership, Etc.: ______________________________________________________ Valuation Date: _______________ Business Loan(s) Balance: _______________ Value of Interest: ______________ q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ _________________________________________ Page 5 of 10 Case No. I. OTHER ASSETS – Cash, Travelers Checks, Debts Others Owe You, Copyrights, Trademarks, Pets or Animals, Jewelry, Collectibles, Tools, Inventions, Other “Liquid Assets,” etc. (If more than 5 items, continue on a separate sheet) Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below. H. HOUSEHOLD GOODS: Are you making a non-marital claim ? q Yes q No If yes, you must comply with Section IX below. Agreed Division? = Attached is a list of the disputed household items More BUSINESS INTERESTS attached? q Ye s q No __________________________ Total Values: Name of Business & Owner: _____________________________________________________________________ ___ Percentage of Ownership: ___________ Type of Business: __________________________________________ Corporation, Sole Proprietorship, Partnership, Etc.: ______________________________________________________ Valuation Date: _______________ Business Loan(s) Balance: _______________ Value of Interest: ______________ Item 1: Item Description: _________________________________________________________________________________ Who Holds Possession: ____________________________ Valuation Date: ________________________________ Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________ Item 2: Item Description: _________________________________________________________________________________ Who Holds Possession: ____________________________ Valuation Date: ________________________________ Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________ Item 3: Item Description: _________________________________________________________________________________ Who Holds Possession: ____________________________ Valuation Date: ________________________________ Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________ Item 4: Item Description: _________________________________________________________________________________ Who Holds Possession: ____________________________ Valuation Date: ________________________________ Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________ Item 5: Item Description: _________________________________________________________________________________ Who Holds Possession: ____________________________ Valuation Date: ________________________________ Fair Market Value: ______________ Amount Owed: ____________________ Net Value or Equity: ______________ More OTHER ASSETS attached? q Yes q No Total Values: ____________________ q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 6 of 10 Case No. _________________________________________ VI. OTHER DEBTS NOT PREVIOUSLY LISTED (Do not list account numbers) Includes credit card balances, credit union loans, signature loans and other unsecured debt. (If more than 5 debts, continue on a separate sheet) VII. EXPECTED POST-DIVORCE LIVING EXPENSES SCHEDULE (Do not include debts) Not necessary if maintenance or child support are not being claimed. Do the parties’ combined gross incomes exceed $15,000 per month ? q Ye s q No If NO , do not include children’s personal expenses below. If YES , lis t children’s personal expenses such as private school tuition, tutors, camps, activity fees, clothing, etc. on a separate sheet. q Attached More DEBTS attached? q Ye s q No Total Debt Balances: __________________ Creditor: ________________________________________________________________________________________ Party Named on Debt: _____________________________________________ Premarital Account? _____________ Valuation Date: __ _____ _____________ Monthly Payment: ________________ Total Balance: _________________ Creditor 1: Creditor: ________________________________________________________________________________________ Party Named on Debt: _____________________________________________ Premarital Account? _____________ Valuation Date: __ _____ _____________ Monthly Payment: ________________ Total Balance: _________________ Creditor 2: Creditor: ________________________________________________________________________________________ Party Named on Debt: _____________________________________________ Premarital Account? _____________ Valuation Date: __ _____ _____________ Monthly Payment: ________________ Total Balance: _________________ Creditor 3: Creditor: ________________________________________________________________________________________ Party Named on Debt: _____________________________________________ Premarital Account? _____________ Valuation Date: __ _____ _____________ Monthly Payment: ________________ Total Balance: _________________ Creditor 4: Creditor: ________________________________________________________________________________________ Party Named on Debt: _____________________________________________ Premarital Account? _____________ Valuation Date: __ _____ _____________ Monthly Payment: ________________ Total Balance: _________________ Creditor 5: q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 7 of 10 Case No. _________________________________________ A. COMMON EXPENSES FOR FAMILY (Party and any childre n of the marriage) FOOD/GROCERIES FOR FAMILY (Non-entertainment) B. YOUR PERSONAL EXPENSES ( not including any children’s expenses) Church and charitable donations Clothing Cosmetics, hygiene & toiletries Disability insurance Dry cleaning & laundry Entertainment, including restau rants & movies Hair c are (barber, salon, etc.) Internet access Life insurance (whole life or term) Manicures & pedicures Newspapers, magazines & books Professional dues or uniforms Sports, exercise, hobbies, crafts, etc. Travel (monthly average) MEDICAL Dental (including orthodontics) Eyeglasses, co ntacts & hearing aids, exams and testing Insurance (hospitalization) Medical doctor(s) Prescription medication OTHER PER SONAL EXPENSES (list): Su b-total from attached other personal expenses, if needed q Attached SUBTO TAL FROM COLUMN B SUBTOTAL FROM COLUMN A SUBTOTAL FROM CHILDREN’S EXPENSE LIST ATTACHMENT GRAND TOTALof column a, b, and attachments HOUSING Cable Garbage collection Electric, gas, propane & oil utilities Home maintenance & repairs Homeowner’s insurance Household supplies Maid service Property taxes Rent or 1st mortgage 2nd mortgage/home equity loan Telephone Mobile phone Vet/pet supplies Yard expense/maintenance Water/sewage TRANSPORTATION Gas and oil Liability insurance License/taxes/tag Payment/loan Repairs/maintenance Other – bus, taxi, tolls & parking OTHER FAMILY EXPENSES (list): Sub-total from attached other family expenses, if needed q Atta ched SUBTOTAL (Column A) q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 8 of 10 Case No. _________________________________________ VIII. OTHER A. Spec ial needs of parties: ________________________________________________________________________\ _________________ ________________________________________________________________________\ _________________ ________________________________________________________________________\ _________________ B. Bankruptcy: ______________________________________________________________________________ C. Lawsuits: _________________________________________________________________________\ ________ IX. REQUIRED ATTACHMENTS (to be sent ONLY to opposing party or opposing counsel and not filed with the Court): To complete this section, you must attach all of the following documents and/or provide the requested information on a separate sheet and attach to this form. In the spaces provided, mark as follows: “A” = to indica te that the requested document/information is attached. “U” = to indicate that the requested document/information is unavailable (Provide explanation on a separate page) “N/A” = if not applicable A. PERSONAL INFORMATION OF BOTH PARTIES B. INCOME AND EMPLOYMENT OF BOTH PARTIES A, U, N/A Item # 1. Three (3) most recent paycheck stubs 2. Federal Income Tax Return for the last year filed 3. State Income Tax Return for the last year filed 4. Documentation of all other i ncome for the past 48 months, including source of income and amount of income received year-to-date A, U, N/A Item # 1. Verification of work-related child care expenses 2. Verification of cost of health/dental insurance for children’s portion (e.g. difference between cost of single and family plan) C. CHILDREN D. ASSET SCHEDULES A, U, N/A Item # 1. Most recent statement of each bank account 2. Most recent brokerage statement or documentation of purchase and/or value for each investment 3. Explanation of source of cash holdings, location and amount of cash 4. For each piece of real estate, copy of deed, documentation of all indebtedness (i.e., mortgage, home equity loan, liens, etc.) including unpaid balance and payof f (with date payoff amount obtained ) for each debt, and current tax assessment 5. Declaration page of life insurance policies and documentation of cash surrender q AOC-238 Doc. Code DSPV q AOC-239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 9 of 10 Case No. _________________________________________ A, U, N/A Item # 6. Documentation of benefits accrued in pension, profit sharing, 401(k) or other retirement plans, including most recent statements of each such plan and the name, address and phone number of plan administrator 7. For each vehicle, provide amount of payoff of any indebtedness (including date payoff amount obtained) and copy of title 8. For each business interest, list name of business, extent of interest or title in business (i.e. owner, shareholder, partner, etc.), provide a copy of last income tax return filed by business and documentation of income earned (or portion received) through business during last twenty-four (24) months 9. Provide a list describing any other assets you have an interest in, including any documentation as to the value of the non-marital interest, date asset was acquired, and source of non-marital interest (trace and document non-marital funds used to acquire each asset) 10. NON-MARITAL INTEREST. For each asset in which you claim a non-marital interest, provide the basis and approximate value of non-marital claim. Documentation tracing any non-marital asset shall be produced if available, and if not currently available, shall be produced when available, or as specified by separate court order E. DEBT SCHEDULE A, U, N/A Item # 1. For each debt, provide the last statement or documentation of unpaid balance, or explain why documentation is not available 2. For each debt designated as “non-marital”, list the party you think should assume responsibility for said debt and why VERIFICATION I, ________________________________________, declare under penalty of perjury that the information contained herein, including the information provided on any schedules and attachments, is true and accurate to the best of my knowledge, information and belief. Further, I acknowledge that I have read the foregoing instructions and have followed those instructions to the best of my a bility. ______ ____________ __________________________ q P etitioner q Respondent {check one } q AOC-238 Doc. Code DSPV q AOC 239 Doc. Code DSFV Rev. 1-15 Disclosure of _____________________________________ Page 10 of 10 Case No. _________________________________________ STATE OF ____________________________ ) ) SS COUNTY OF ____________________________ ) Subscribed and sworn before me by ____________________________ , this _____ day of _________________, ________. My commission expires: ______________________ _____ _________________________________ NOTARY PUBLIC/TITLE *NOTE When this form is utilized as an AOC-238, Preliminary Verified Disclosure Statement, unless otherwise ordered by the Court or required by Local Rule, this form is NOT to be filed with the Court . FCRPP 2(3). However, the entire form and all attachments are to be exchanged between the parties within 45 days of service of the petition on the respondent, and objections thereto shall be exchanged within 20 days thereafter . When this form is utilized as an AOC-239, Final Verified Disclosure Statement, pursuant to FCRPP 3(3), this form is to be filed with the Court no later than 5 days prior to the trial if property matters are in dispute at that trial. However, the parties may file an AOC-239.2, Affidavit of No Change in Circumstances, since the completion of the AOC-238, Preliminary Verified Disclosure Statement, IF one was filed with the Court. A copy of the Final Verified Disclosure Statement or the Affidavit, together with any supporting documentation, shall be provided to the opposing party 15 days prior to trial unless otherwise ordered by the Court. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy of this Verified Disclosure Statement (with schedules and attachments) was served by q mail, postage prepaid, or q hand-delivery, or q electronic means, in accordance with Kentucky Rule of Civil Procedure (CR) 5.02, on ( name ) _____________________________________________________________________ at ( address ) _____________________________________________________________________________________, this the _______ day of __________ ______________, _________. __ __________________________________________ Signature q Attorney for Petitioner q Attorney for Respondent q Petitioner q Respondent Address : ____________________________________________ ____________________________________________ ____________________________________________ Phone: ( ) ________________________________ Fax: ( ) _________________________________ Email: _____________________________________