Fill and Sign the Petitioner Pro Se Montana Fourth Judicial Form

Declaration of Disclosure, Page 1 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 _______________________________ Name _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Phone Number [ ] PETITIONER/[ ] RESPONDENT PRO SE MONTANA _______________ JUDICIAL DISTRICT COURT _____________________ COUNTY In re the Marriage of: ________________________, Petitioner, and ________________________, Respondent.Cause No.: _________________ [ ] Petitioner’s/[ ] Respondent’s [ ] Preliminary/[ ] Final Declaration of Disclosure of Assets, Debts, Income, and Expenses Warning: Montana law, M.C.A. § 40-4-252, requires the full disclosure of all assets, debts, income, and expenses. Failure of either party to file a complete financial disclosure statement shall authorize the Court to accept the statement of the other party as accurate. Any deliberately false statement made hereon or on any schedules or attachments may subject you to the penalty of perjury or other appropriate relief and may be considered a fraud upon the Court. If you need additional space on which to list your assets, debts, income, or expenses, please attach additional sheets of paper as necessary. Do not write in the margins or on the reverse sides of the pages of this document. Declaration of Disclosure, Page 2 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 1. Disclosure of Assets a. Real Estate Description Est imat ed Value Name(s) on Title Address: ___________________________________ Legal Description:____________________________ ___________________________________________ Is there a secured debt on the property? [ ] Yes [ ] No If yes, amount owed: __________ As of: / / Lender: ____________________________________ Address: ___________________________________ Legal Description:____________________________ ___________________________________________ Is there a secured debt on the property? [ ] Yes [ ] No If yes, amount owed: __________ As of: / / Lender: ____________________________________ b. Vehicle(s) Description Est imat ed Value Name(s) on Title Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ Description Est imat ed Value Name(s) on Title Declaration of Disclosure, Page 3 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ c. Bank Accounts and Cash Description (include name of bank and account number)Balance as of / / Name(s) on Account Cash XXXXXXXX d. Pensions/Retirement Accounts; Life Insurance (Cash Value); Stocks, Bonds, Secured Notes, Mutual Funds Description Est imat ed Value Name(s) on Account Declaration of Disclosure, Page 4 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 e. Personal Property (including appliances, furniture, jewelry, art, guns, etc.) Description Est imat ed Value Declaration of Disclosure, Page 5 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 f. Business Interests (including equipment, tools, livestock, etc.) Description Est imat ed Value Name(s) on Title g. Other Assets Description Est imat ed Value Name(s) on Title 2. Disclosure of Debts Description Creditor Amount Owed Name on Debt Secured Debt on Real Property(See 1(a) above) XXXXX XXXXXXXXX Vehicle Loan(s) (See 1(b) above)XXXXX XXXXXXXXX Ut ilit y Bill(s): Description Creditor Amount Owed Name on Debt Declaration of Disclosure, Page 6 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 Credit Card(s): Student Loan(s): Medical Expenses: Ot her Liabilit ies: 3. Disclosure of Income The [ ]Petitioner/ [ ]Respondent has the following income: Source of Income Amount per Month Gross Wages, Salary, Commissions Rents, Interests, Dividends Self Emplo yment Earnings Unemployment or Worker’s Compensation Social Security Benefits, including SSI Public Assistance Food Stamps Source of Income Amount per Month Declaration of Disclosure, Page 7 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 Pension, Retirement Child Support Dependent’s Benefits Other Income (describe): 4. Disclosure of Expenses The [ ] Petitioner/[ ] Respondent has the following expenses: Description of Expense Amount per Month Taxes and other money withheld from income Retirement Health Insurance (self and children) Medical Expenses Housing (rent or mortgage payment) Property Taxes Property Insurance Transportation Car Insurance Student Loans Ut ilit ies Telephone Clothing Food and Household Supplies Child Care Description of Expense Amount per Month Declaration of Disclosure, Page 8 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 Child Support Payments Other Expenses (describe): DATED this ____ day of _______________________, 20___. Signature Print Name [ ]Petitioner/ [ ]Respondent Pro Se STATE OF MONTANA ) ) ss. COUNTY OF ) SUBSCRIBED AND SWORN TO before me this _____ day of ____________________, 20____. Name (printed): _______________________ (Seal) Notary Public for the State of Montana Residing at My commission expires