Fill and Sign the Wisconsin Assets Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE INTEREST OF       Name Statement of Income, Assets, Debts and Living Expenses       Date of Birth Case No.       Under penalty of perjury, I state that the following information on this financial statement is true, accurate and complete: Name of Person Completing Form       Name of Father's Employer       Number of People in Household       Adults       Children Name of Mother's Employer       STATEMENT OF MONTHLY HOUSEHOLD INCOME (If there are insufficient columns for all household members, attach additional schedules.) Father Mother Other House-hold Members Salary and wages (If weekly or biweekly, compute as a monthly figure.)                   Other income: (Pensions, retirement, social security, disability, worker's compensation, public assistance)                   Child support and/or maintenance from prior spouse                   Dividends, interest, rents, bonuses                   Other:                         Total Monthly Income                   Itemized mandatory monthly deductions: (Do not include savings or credit union deductions not required by law.) Federal and state income taxes, social security, Medicare                   Union or other dues                   Retirement and pension funds                   Other mandatory monthly deductions:                   Total Mandatory Monthly Deductions                   Net Monthly Income                   STATEMENT OF ASSETS Asset Description Fair Market/ Cash Value Real estate (List kind of property and location)             Other real estate (List kind of property and location)             Vehicle (Give year and make)             Other vehicles (Give year and make)             Checking account (Give name of financial institution)             Savings account (Give name of financial institution)             IRA/Pensions/Profit Sharing (Identify by name)             Life insurance with cash value (Identify by name of company)             Stocks/Bonds/Certificates of Deposit             Other assets valued over $200             Total Value of Assets       JD-1718 , 06/03 Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Statement of Income, Assets, Debts and Living Expenses Page 2 of 2 Case No. LONG TERM DEBTS AND MONTHLY EXPENSES Long Term/Installment Debts Creditor Name Balance Owed Monthly Payment Mortgage Payment (Include property taxes and insurance if included in payment.)                   Credit Cards                   Automobile Loans                   Other:                         Other:                         Other:                         Total Owed       Other Monthly Debts/Expenses Rent (Do not duplicate mortgage payment above.)       Repairs/maintenance on home       Food       Electricity/water/heat       Telephone       Laundry and dry cleaning       Child support paid for children not in your home       Maintenance paid to an ex-spouse       Clothing and shoes       Health insurance premiums       Medical/dental/drug expenses not covered by insurance       Life insurance premiums       Other insurance premiums (specify):             Child care       Cable TV       Transportation costs (oil/gas/commuting)       School       Entertainment/incidentals/newspapers/books/periodicals       Hobbies       Other:             Other:             Other:             Total Monthly Payments       Complete this form and return it to the juvenile court clerk so that it arrives by the time indicated on the court order. Signature       Date Signed JD-1718 , 06/03 Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2