Kentucky Self-Help Divorce Packet with Children

ACKNOWLEDGMENT OF DISCLOSURE STATEMENT

IN RE THE MARRIAGE OF:

All sections must be completed. If an amount is unknown, write "unknown", if the question is inapplicable, write "N/A”.

If a question requires further documentation or an additional schedule, please attach. If maintenance is an issue or there are property distribution issues, please proceed to use the full Mandatory Case Disclosure Form.

I, declare under oath that my personal information is:

Name:

Address:

Age/Place birth:

Date/Place marriage:

Spouse's name:

Spouse's age:

I am currently employed at:

I earn per

****** My total gross monthly income (from all sources) is

OTHER LEGAL ACTIONS

Please give the style, the case number, and the name of the Court or administrative agency for any case you are a party in or have been within the last year as well as a brief description of the nature of the case and present status.

REQUIRED ATTACHMENTS

"A" = to indicate 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

I have provided a copy of the following documents to opposing party or opposing counsel:

1. My three (3) most recent pay stubs

2. A full and complete copy of my last Federal Tax Return

3. First page of my last State Tax Return

I hereby acknowledge that the information contained in 's Verified Disclosure Statement is a true and accurate reflection of the financial disputes in this matter and that there are no additional assets, debts or issues which require disclosure to the best of my knowledge and belief. Further, I hereby certify that the foregoing information is true to the best of my knowledge, information and belief.

STATE OF

COUNTY OF SS

)

Subscribed and sworn before me by this day of

My commission expires:

NOTARY PUBLIC/TITLE

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a copy of this Acknowledgment Of Verified Disclosure Statement (with schedules and attachments) was served by mail, postage prepaid, orhand-delivery, or electronic means, in accordance with Kentucky Rule of Civil Procedure (CR) 5.02, on (name)

at (address)

this the day of

*NOTE

When this form is utilized in lieu of the 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 in lieu of the AOC-239, Final Verified Disclosure Statement, or AOC-239.2, Affidavit of No Change in Circumstances, 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. A copy of this Acknowledgment shall also be provided to the opposing party 15 days prior to trial unless otherwise ordered by the Court.