STATE OF WISCONSIN CIRCUIT COURT  ______COUNTY

FAMILY COURT BRANCH

In re the marriage

______, Petitioner

and

______, Respondent

Preliminary Financial Disclosure Statement

of ___Husband___Wife

Case # _____ FA ______

Family ABCDE

Husband / Wife
Name: ______/ Name: ______
Address: ______
______/ Address: ______
______
Soc. Sec. No. ______/ Soc. Sec. No. ______
Birthdate: ______Age: ______/ Birthdate: ______Age: ______
Employer: ______/ Employer: ______
Address: ______
______/ Address: ______
______
Occupation: ______/ Occupation: ______
Date of Marriage: ______/ Date of Filing Summons: ______
Date of Service: ______/ Date of Separation: ______
Children
Name / Birthdate / Age / Social Security Number
______/ ______/ ______/ ______-______-______
______/ ______/ ______/ ______-______-______
______/ ______/ ______/ ______-______-______
Children are currently living with ______

I. Statement of Gross Monthly Income & Monthly Deductions

Calculation of Net Monthly Income / Husband / Wife
1. Gross monthly income from salary and wages including
commissions, bonuses, allowances and overtime, payable
[ Weekly, Bi-Weekly, Bimonthly, Monthly ] (circle one) / $ ______/ $ ______
2. Interest and Dividends / $ ______/ $ ______
3. Rent / $ ______/ $ ______
4. Pensions and retirement / $ ______/ $ ______
5. Social Security / $ ______/ $ ______
6. Disability and unemployment Insurance / $ ______/ $ ______
7. Public Assistance / $ ______/ $ ______
8. Child Support from any prior marriage / $ ______/ $ ______
9. All other sources: (please specify) ______/ $ ______/ $ ______
Gross Monthly Income (add lines 1 through 9) / $ ______ / $ ______
Calculation of Monthly Deductions / Husband / Wife
1. Federal Income Tax / $ ______/ $ ______
2. State Income Tax / $ ______/ $ ______
Number of exemptions taken by husband ______,
by wife______. / $ ______/ $ ______
3. Social Security/Medicare / $ ______/ $ ______
4. Health Insurance / $ ______/ $ ______
5. Other Insurance (please specify) ______/ $ ______/ $ ______
6. Union and other dues / $ ______/ $ ______
7. Retirement or pension fund / $ ______/ $ ______
8. Savings Plan / $ ______/ $ ______
9. Credit Union / $ ______/ $ ______
10.Other (please specify) ______
______/ $ ______/ $ ______
Total Monthly Deductions (add line 1 through 10) / $ ______ / $ ______
Net Monthly Income / Husband / Wife
(subtract Monthly Deductions from Gross Monthly Income) / $ ______/ $ ______

II. Statement of Debts and Other Monthly Obligations

Creditor's Name / For / Date Payable / Balance / Payment
______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______
______/ ______/ ______/ ______/ ______

(if insufficient space, insert total and attach schedule)

III. Schedule of Assets

All property of the parties known to me owned individually or jointly

(indicate who holds or how title held: (H) Husband, (W) Wife, or (J) Jointly)

Value / Owed thereon
1. Household furnishings
furniture, appliances and equipment / $ ______/ $ ______
In Wifes possession / $ ______/ $ ______
In Husbands possession / $ ______/ $ ______
2. Automobile (year-make-model)
______/ $ ______/ $ ______
______/ $ ______/ $ ______
3. Securities (stocks, bonds, mutual funds)
______/ $ ______/ $ ______
______/ $ ______/ $ ______
______/ $ ______/ $ ______
4. Cash and Deposit Accounts (banks, savings & loans, credit unions - savings and checking)
______/ $ ______/ $ ______
______/ $ ______/ $ ______
______/ $ ______/ $ ______
______/ $ ______/ $ ______
______/ $ ______/ $ ______
______/ $ ______/ $ ______
5. Life Insurance Name of Company/Policy No./Face Amount/I=Insured/O=Owner/ B=Beneficiary/Value=Net Cash Surender Value
______
______
______
______
6. Profit Sharing, Pension, Retirement Accounts
______
______
______
______
7. Other Personal Property and Assets (Describe fully)
______
______
______
______
  1. Real Estate
Where more than one parcel of real estate owned, attach sheet with identical information for all additional property
Address: ______
Original Cost $______/ Type of Property:______
Cost of Additions $______/ Date of Acquisition:______
Total Cost $______/ Total Present Value: $______
Mrtg.Balance $______/ Basis of Valuation:______
Monthly Mrtg Pymt $______/ Taxes (199____): $______
Other Liens $______/ To:______
Monthly Lien Pymt $______
Equity $______/ To:______
Individual contributions______
9. Business Interests
(Indicate name, share, type of business, value less indebtedness)
______
______
______
______
10. Individual (gifted/inherited) property:
______
______
______
______

IV. Schedule of Monthly Expenses

List name(s) and relationship of all household members whose expenses are included: ______

______

1. Rent or mortgage payments (residence) / 1. $______
2. Real property taxes (residence) / 2. $______
3. Real property insurance (residence) / 3. $______
4. Maintenance/replacement (home and household contents) / 4. $______
5. Food and household supplies / 5. $______
6. Utilities including water, electricity, gas and heat / 6. $______
7. Telephone / 7. $______
8. Laundry and cleaning / 8. $______
  1. Clothing/shoes
/ 9. $______
  1. Medical/drug (not covered by insurance)
/ 10. $______
  1. Dental
/ 11. $______
  1. Insurance (life, health, accident, comprehensive, liability, disability--excluding payroll deducted)
/ 12. $______
  1. Child care
/ 13. $______
  1. Payment of child/spousal support from prior marriage
/ 14. $______
  1. School
/ 15. $______
  1. Entertainment (including clubs, social obligations, travel, recreation)
/ 16. $______
  1. Incidentals (grooming, tobacco, alcohol, gifts, and donations)
/ 17. $______
  1. Transportation (other than automobile)
/ 18. $______
  1. Auto expenses (gas, oil, repairs, insurance)
/ 19. $______
  1. Auto payments
/ 20. $______
  1. Installment payment(s) (see schedule of debts above)
/ 21. $______
  1. Other expenses (please specify) ______
/ 22. $______
Total Monthly Expenses / $______

V. Litigation

  1. Are you a party to any other lawsuits?  YES  NO

If YES, please provide details: ______

______

  1. Do you have any claim against anyone? (e.g., personal injury, property damage, breach of contract)

 YES  NO

If YES, provide details:______

______

  1. Have you ever filed bankruptcy?  YES  NO

If yes, please provide details: ______

______

Attachments (check if attached):

Tax returns for years ______

Wage statements for period ______

Copy of current health care insurance policy/plan naming child(ren) as beneficiary

Information regarding the types and costs of any health insurance policies or plans offered through (petitioner's / respondent's) employer or other organization.

I declare under penalty of perjury that the foregoing, including any attachments, is true and correct and that this declaration was executed on the ______day of ______, ______, at ______(city), Wisconsin.

______

___WIFE ___HUSBND