Fill and Sign the Rule 805 Financial Disclosure 10th District Chancery Court Form

IN THE CHANCERY COURT OF COUNTYTHE STATE OF MISSISSIPPI EXHIBIT "A" PLAINTIFF CIVIL ACTION NUMBER DEFENDANT ********************************************************************* I. GENERAL INFORMATION NAME: ADDRESS: CITY, STATE AND ZIP CODE: DATE OF BIRTH: SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER: EMPLOYER'S ADDRESS: NAME DATE OF BIRTH MINOR CHILDREN: II. INCOME STATEMENT GROSS MONTHLY INCOME AMOUNT 1. Salary and Wages, including commissions, 1. bonuses, allowance and overtime NOTE: To arrive at a monthly income figure if paid weekly, multiply weekly income by 4.3, if paid bi-weekly, multiply income by 2.16 2. Pensions and retirement 2. 3. Social Security 3. 4. Disability and unemployment insurance 4. 5. Public assistance (welfare, AFDC payments, 5. etc.) 6. Dividends and interest 6. 7. Rental income 7. 8. Other income 8. 9. Other income 9. 10. TOTAL MONTHLY INCOME 10. ITEMIZED MONTHLY DEDUCTIONS: 1. State Income Taxes1. 2. Federal Income Taxes 2. 3. Social Security 3. 4. Mandatory Insurance 4. 5. Mandatory Retirement 5. 6. Union or other dues 6. 7. Other: (Specify) 7. 8. Other: 8. 9. TOTAL MONTHLY DEDUCTIONS 9. 10. NUMBER OF EXEMPTIONS: 10. 11. NET MONTHLY PAY 11. III. EXPENSE STATEMENT A. LIVING EXPENSES AS OF AS OF Self Children Self Children 1. Rent/Mortgage (Residence) 2. Real Property Taxes 3. Real Property Insurance 4. Maintenance (Residence) 5. Food/Household Supplies 6. Water, Sewer, etc. 7. Electricity 8. Gas (Residence) 9. Telephone 10. Laundry & Cleaning 11. Clothing 12. Insurance (Not payroll deducted) 13. Medical 14. Dental 15. Child Care 16. Children's allowance 17. Payment of child support/alimony (Prior marriage) 18. School Expenses 19. Entertainment 20. Incidentals & Miscellaneous 21. Transportation other than vehicle 22. Gasoline & Oil (auto) 23. Repair (auto) 24. Insurance (auto) 25. Auto Payments 26. Church donations 27. Charitable donations 28. Newspaper/Magazines 29. Cable TV 30. Pet Expenses 31. Yard Expenses 32. Maid 33. Retirement (IRA etc.) 34. Pest Control B. TOTAL LIVING EXPENSES: 35. Installment PaymentsNotes, loans, charge accounts, etc. 36. 37. 38. 39. OTHER EXPENSES: 40. 41. _ TOTAL INSTALLMENT PAYMENTS: COMBINED TOTAL EXPENSES: EXHIBIT "B" IV. STATEMENT OF ASSETS A. Real Estate 1. Title in the name of: Address: Who paid cost: How cost paid: Value (estimate) Mortgage Balance Equity 2. Title in the name of: Address: Who paid cost: How cost paid: Value (estimate) Mortgage Balance Equity * List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under LIABILITIES. B. Motor Vehicles 1. Registered in the name of: Year: Model: Mileage: How cost paid: How cost paid: VALUE - Loan balance = Equity 2. Registered in the name of: Year: Model: Mileage: How cost paid: How cost paid: VALUE _______________ - Loan balance = Equity 3. Registered in the name of: Year: Model: Mileage: How cost paid: How cost paid: VALUE - Loan balance = Equity C. Other Personal Property (such as home computers, guns, lawnmowers, TVs, jewelry, household furnishings, etc.) VALUES TOTAL: D. Checking/Savings (name of Bank, Account Number and Amount in Account, including CDs, money markets, passbook accounts, etc. Name(s) on Account Bank/Account Number Type Account Balance TOTAL VALUE E. Other Investments (IRAs, stock(s), mutual funds, pension plans, etc.) Bank/Account Number Type Investment Balance F. Life Insurance (exclude children) Insured Company Face Amount Cash Beneficiary TOTAL CASH VALUE (less loans) G. All Other Assets TOTAL VALUE TOTAL OF ALL ASSETS $      V. STATEMENT OF LIABILITIES (Include mortgage, car loan, credit cards, personal loans) Note : Also include under items 35-44 on Exhibit “A” A. Creditor Party Responsible Current Balance Monthly Payment Who Makes for Payment Payments 1. 2. 3. 4. 5. 6. B. TOTAL LIABILITIES ACKNOWLEDGMENT OF TRUTHFULNESS I declare to the Court that the foregoing Exhibits “A” and “B,” including attachments, are true and correct and that this declaration was executed on the day of , 200 . Party’s Signature