Fill and Sign the Order Financial Disclosure Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY Order for Financial Disclosure and Financial Disclosure Statement Case No.       Creditor:       -vs- Debtor:       SC-506 , 10/05 Order for Financial Disclosure and Financial Disclosure Statement Wis. Stats. §§799.26, 812.34 and 812.39 This form shall not be modified. It may be supplemented with additional material. Order for Financial Disclosure and Financial Disclosure Statement Page 2 of 5 Case No . IT IS ORDERED THAT the judgment debtor within 15 days of entry of judgment either  Pay the judgment in full, or  Accurately complete the following Financial Disclosure Statement and mail or deliver it to the judgment creditor or attorney at the following address: Name:       Address:        Failure to comply with this order may be contempt of court and subject you to the following penalties:  Imprisonment for up to 6 months .  Forfeitures of not more than $2000 per day.  Any other order necessary to ensure your compliance.  Punitive (criminal) sanctions under Wis. Stats. Ch. 785. BY THE COURT : Judgment Date Circuit Court Judge/Circuit Court Commissioner Date Individuals should complete items 1 - 35 and 37. Corporations should complete items 25 - 33, 36 and 37. FINANCIAL DISCLOSURE OF ASSETS 1. Your full name 2. Date of Birth 3. Social Security Number 4. Number of Dependents 5. Your residence address (not P.O. box) City State Zip Code Phone No. 6. Spouse’s full name 7. Social Security Number 8. Do you have a marital property agreement? Yes (Attach copy.) No 9. Spouse’s residence address (if different) City State Zip Code Phone No. 10. Your employer’s name and address 11. Gross Wages 12. Paid weekly biweekly monthly 13. Spouse’s employer’s name and address 14. Gross Wages 15. Paid weekly biweekly monthly You must complete this information (16 – 33 ) for both you and your spouse. 16. Other employers 17. Gross Wages 18. Paid weekly biweekly monthly 19. Pension income (Give name and address of payor.) 20. Amount 21. Paid weekly biweekly monthly 22. Social Security/Disability/SSI (Give name and address of payor.) 23. Amount 24. Paid weekly biweekly monthly 25. Checking, savings, financial accounts (List name and address of institution, type of account and amount.) 26. Automobiles (Give year, make and market value.) 27. Stocks, bonds, life insurance, IRA’s and other financial investments (List name, number of shares and value.) 28. Other Income (Specify) 29. Real estate and other real property interests (List kind of property, location and market value.) 30. Does anyone owe you money? Yes (Attach details.) No 31. Is anyone holding any assets or property for you? Yes (Attach details.) No 32. Amount of cash on hand 33. Other assets of value (Give details and values.) Complete both pages and sign page 2. SC-506 , 10/05 Order for Financial Disclosure and Financial Disclosure Statement Wis. Stats. §§799.26, 812.34 and 812.39 This form shall not be modified. It may be supplemented with additional material. Page 2 of 5 Order for Financial Disclosure and Financial Disclosure Statement Page 3 of 5 Case No . 34. Do you believe your earnings are exempt from garnishment? Yes No If yes, complete lines A, B, and C as appropriate. A. I have received the following need-based public assistance within the last six months: Medical assistance Relief funded under Wis. Stats. §59.53(21) Food stamps Relief funded under public assistance Supplemental security income Benefits for veterans under Wis. Stats. §45.351(1) or 38 USC 501-562 B. I have been determined to be eligible to receive the following need-based public assistance although I have not actually begun to receive those benefits: Medical assistance Relief funded under Wis. Stats. §59.53(21) Food stamps Relief funded under public assistance Supplemental security income Benefits for veterans under Wis. Stats. §45.351(1) or 38 USC 501-562 C. My household income is below the federal poverty line. (Worksheets and schedules for this determination are available in the Clerk of Court’s Office.) D. At least 25% of my disposable earnings are assigned by the court order for support. 35. Would the garnishment of 20% of your disposable income reduce your household income below the federal poverty line? Yes No 36. Corporations should complete questions 25 – 33, as well as the following: Name of Corporation Address Taxpayer ID Number Officers of Corporation and Title Business Address Home Address 1. 2. 3. 4. Registered Agent Address 37. The information provided on this statement is true and correct.       Signature of Judgment Debtor/Corporate Officer       Date SC-506 , 10/05 Order for Financial Disclosure and Financial Disclosure Statement Wis. Stats. §§799.26, 812.34 and 812.39 This form shall not be modified. It may be supplemented with additional material. Page 3 of 5 GARNISHMENT, EXECUTIONS AND EXEMPTIONS An unpaid money judgment against you can result in the judgment creditor satisfying the judgment by taking or selling your personal property, including income, and your real estate. Garnishment is a separate legal proceeding used to take money in possession of another which is owed you, typically income or deposits in fnancial institutions, in an amount sufcient to satisfy the judgment. A separate garnishment proceeding must be commenced by a judgment creditor choosing this remedy. Execution is a writ issued by a court directing the sherif to seize or attach your personal property or real estate so that it may be sold to satisfy the judgment. A writ of execution can be issued upon the perfecting and docketing of the original judgment without commencement of a separate legal proceeding. Exemptions are assets protected by statute from garnishment and execution. These assets are determined in part by your marital status, the number of your dependents, whether the transaction leading to the judgment was a consumer credit transaction and whether the judgment creditor had a mortgage or a security interest. Other qualifcations and limitations are set forth in §815.18(3) through (13), Wisconsin Statutes. Because your personal circumstances will determine if an asset is exempt from execution, the Judicial Conference can only inform you about the types of assets and amount of income which MAY be exempt and the statutes you can refer to for specifc information. Your exempt assets and income with statutory limitations may include the following:  Salary up to 10% for purchase of savings bonds [Wis. Stats. §20.921(1)(e)].  Veteran's benefts [Wis. Stats. §45.35(8)(b)].  Assistance grants [Wis. Stats. §49.96].  Pension funds and benefts from 1st class cities and counties of populations over 500,000 [Wis. Stats. §62.63(4) and Ch. 201, Laws 1937, s.11].  Worker's compensation awards [Wis. Stats. §102.27(1)].  Unemployment compensation benefts [Wis. Stats. §108.13(2)].  School aid moneys [Wis. Stats. §121.007].  Partner's rights in specifc partnership property [Wis. Stats. §178.21(3)(c)].  Tenant's housing corporation lease and stock interests [Wis. Stats. §182.004(6)].  Income, including wages and earnings [Wis. Stats. §§425.106(1)(a), 812.34(2), 812.39 and 815.18(3)(h)].  Clothing, jewelry, household furniture and furnishings [Wis. Stats. §425.106(1)(b)].  Homestead interest in real estate [Wis. Stats. §425.106(1)(c), 815.20 and 815.21].  Earnings or assets required to be paid by customers as restitution [Wis. Stats. §425.106(1)(d)].  Insurance company deposits with the State Treasurer [Wis. Stats. §601.13(7)].  Fraternal benefts [Wis. Stats. §614.96].  Cemetery lots, above ground burial facilities/monuments, tombstones and cofns [Wis. Stats. §815.18(3)(a)].  Business and farm equipment, inventory, products and professional books not to exceed $7500 [Wis. Stats. §815.18(3)(b)].  Child support, family support or maintenance payments [Wis. Stats. §815.18(3)(c)].  Consumer goods held primarily for personal, family, or household use not to exceed $5000 [Wis. Stats. §815.18(3)(d)].  State aid to county fairs and agricultural societies [Wis. Stats. §815.18(3)(df)].  Federal disability insurance benefts [Wis. Stats. §815.18(3)(ds)].  Fire and casualty insurance proceeds [Wis. Stats. §815.18(3)(e)].  Fire and police pension fund benefts [Wis. Stats. §815.18(3)(ef)].  Fire apparatus and equipment [Wis. Stats. §815.18(3)(em)].  Life insurance contract and accrued dividends, interest or loan value not to exceed $4000 [Wis. Stats. §815.18(3)(f)].  Motor vehicles not to exceed $1200 plus unused consumer goods value [Wis. Stats. §815.18(3) (g)].  Life insurance, personal injury and wrongful death claims [Wis. Stats. §815.18(3)(i)]. SC-506 , 10/05 Order for Financial Disclosure and Financial Disclosure Statement Wis. Stats. §§799.26, 812.34 and 812.39 This form shall not be modified. It may be supplemented with additional material. Order for Financial Disclosure and Financial Disclosure Statement Page 5 of 5 Case No .  Retirement and public employee trust funds [Wis. Stats. §§40.08(1) and 815.18(3)(j)].  Depository accounts in the aggregate value of $1000 [Wis. Stats. §815.18(3)(k)].  Private property to satisfy judgments against municipalities, vocational, technical and adult education and school districts [Wis. Stats. §815.18(3)(m)].  Federal war pensions [Wis. Stats. §815.18(3)(n)].  Crime victim award [Wis. Stats. §949.07]. SC-506 , 10/05 Order for Financial Disclosure and Financial Disclosure Statement Wis. Stats. §§799.26, 812.34 and 812.39 This form shall not be modified. It may be supplemented with additional material. Page 5 of 5