Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Final Verified Disclosure Statement Form. This is a Kentucky form and can be use in Fayette Circuit Court Local.
Loading PDF...
Tags: Final Verified Disclosure Statement, FC-4, Kentucky Local, Fayette Circuit Court
FC-4. Final
Verified Disclosure
Statement
COMMONWEALTH OF KENTUCKY
FAYETTE FAMILY COURT
DIVISION
IN RE THE MARRIAGE OF :
PETITIONER
VS .
FINAL VERIFIED
DISCLOSURE STATEMENT
NO.
-CIRESPONDENT
Petitioner 0 Respondent submits under oath the following Final Verified Disclosure
Statement pursuant to RFCC 14 .0(H)(3)(a) :
N
A RESPONSE OF "SEE ATTACHED" IS NOT APPROPRIATE FOR ANY
PORTION OF THIS STATEMENT . ATTACH DOCUMENTS REQUESTED
HEREIN ONLY.
A. EMPLOYMENT INFORMATION:
1 . Current Employer:
Address:
Length of Employment:
Present Position :
How Often Paid :
Gross Pay Per Pay Period (including overtime):
Net Pay Per Pay Period (including overtime) : 2. Other/Additional Employer:
Address:
Length of Employment :
Present Position:
How Often Paid:
Gross Pay Per Pay Period (including overtime):
Net Pay Per Pay Period (including overtime) :
3. Self-Employment:
Name of Business :
Type of Business :
Address:
American LegalNet, Inc.
www.USCourtForms.com
Length of Self-Employment :
Present Position :
Gross Income Year to Date:
Ordinary and Necessary Business Expenses Year to Date (list and give totals) :
Gross Income Last Year from Self-Employment:
Net Income Last Year from Self-Employment : ATTACH COPIES OF LAST THREE PAY STUBS FROM EACH EMPLOYER, LAST
YEAR'S W-2(S) AND LAST THREE STATE AND FEDERAL TAX RETURNS .
B. ADDITIONAL INCOME RECEIVED IN LAST 12 MONTHS (Specify amounts) :
1.
Employment Benefits :
Commissions:
Bonuses, incentives, etc.:
Health Insurance paid by employer
Housing expenses :
Automobile expenses:
Payment/lease:
Mileage :
Repairs :
Gas :
Insurance :
Phone/Mobile phone expenses :
Meals or allowance :
Club dues:
Others (list all and specify amount or value) :
2.
Interest and Dividends :
Source
3.
4.
5.
6.
7.
8.
9.
10.
Amount
Unemployment :
Worker's Compensation :
Social Security/SSI :
AFDC:
Child Support:
Maintenance :
Retirement Benefits :
Others (list all and give amounts) :
American LegalNet, Inc.
www.USCourtForms.com
D. CHILD SUPPORT GUIDELINE INFORMATION:
1 . Medical Insurance :
Who pays :
How paid:
How Much for Child(ren) Only :
2 . Dental Insurance :
Who pays :
How paid :
How Much for Child(ren) Only :
3. Child Care Costs :
Who Provides :
How Often is Provider Paid :
Name of Provider:
How Much Paid:
4.
5.
6.
7.
8.
Amt. Paid for Court Ordered Child Support for Prior Born Child(ren) :
Amt. Paid for Court Ordered Maintenance for Prior Marriage(s) :
Imputed Child Support for Prior Born Child(ren):
Child Support Received for Child not of this Marriage :
Maintenance Received from Prior Marriage :
E. NONMARITAL PROPERTY CLAIMS :
List all property, real or personal, tangible or intangible, of greater than $100.00 in value,
which you claim to be either entirely or partially your nonmarital property.
Item 1--Specify item :
Fair Market Value at Date of Marriage :
Debt Balance on Item at Date of Marriage :
Current Debt Balance on Item:
Current Fair Market Value :
Basis for your Claim Item is Nonmarital:
Nonmarital Value of Item :
Item 2--Specify item
Fair Market Value at Date of Marriage :
Debt Balance on Item at Date of Marriage :
Current Debt Balance on Item:
Current Fair Market Value :
Basis for your Claim Item is Nonmarital:
Nonmarital Value of Item:
American LegalNet, Inc.
www.USCourtForms.com
F. MARITAL PROPERTY:
1 . Real Property :
Address
Mortgage(s)
Balance
Fair Market Value
Interest
2. Vehicles, Motorcycles, Boats, Trailers, Equipment, etc. :
Fair Market
Value
YeaWake/ModellType
3. Bank Accounts*
Bank and Type ofAccount
Balance
I
4. Investments (Stocks, Bonds, Mutual Funds, Stock Options, etc.)*:
I # of shares
Type and Location of Investment
5. Life Insurance*:
Co. and Type of Policy
Insured
Loan Balance
Fair Market
Value
Cash
Surrender
Value
Loan
Balance
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements
from retirement plans, periodic statements reflecting assets held in name of or on behalf of
children, and documents reflecting debts and credit card statements for past 12 months
should be in possession of answering party or answering party's attorney when this
statement is served on the opposing party.
American LegalNet, Inc.
www.USCourtForms.com
6 . Assets Held in Name of/on Behalf of Children*
Type & Name of Account
Balance or value
7. Retirement Plans (Pensions, 401(k), Tax Deferred Savings, IRAs, etc.)*:
Balance or Value
Type and Name of Plan
Plan Administrator
8. Interests In/Ownership of Business :
Location of Business,
% and Type of Business
Business Name & Address
9. Household Property in Dispute:
Item
Location
Tax Returns & Financial
Documents
Fair Market
Value
Loan
Balance
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements
from retirement plans, periodic statements reflecting assets held in name of or on behalf of
children, and documents reflecting debts and credit card statements for past 12 months
should be in possession of answering party or answering party's attorney when this
statement is served on the opposing party.
American LegalNet, Inc.
www.USCourtForms.com
10. Safety Deposit Box?
Location
No
Yes
Contents
If yes:
Value
Date of Last
Visit
11 . Other Property - (specify item and value) :
Jewelry:
Furs:
Antiques :
Art:
Collections :
Country Club Memberships:
Season Tickets :
Income Tax Refunds Expected :
Frequent Flyer Miles :
Accounts Receivables/Loans :
Claims Against Others:
Accrued Vacation Pay:
Others:
G. DEBTS* :
* Bank statements, canceled checks, registers, carbon copies of checks, deposit
tickets, periodic statements from investments, statements on life insurance, periodic
statements from retirement plans, periodic statements reflecting assets held in name of
or on behalf of children, and documents reflecting debts and credit card statements for
past 12 months should be in possession of answering party or answering party's
attorney when this statement is served on the opposing party.
American LegalNet, Inc.
www.USCourtForms.com
H . MONTHL Y EXPENSES (Specify amounts) :
Rent:
Mortgage :
^ Property Tax :
_
_
_Homeowner's/Renter's Insurance::
^
House Maintenance :
__
_Electric Utilities :
Fuel, Oil, Gas Utilities :
Telephone:
Cellular Phone:
Water and Sewer:
Garbage P ickup :
Yard Expense :
_Cleaning Service:
Child Care/Bab Y sitter:
Cable Television:
Car Pay m ents/Lea se Payments : ~~
Auto Gas and Oil:
Car Maintenance and Repairs :
Car Licenses/Taxes
_ Car I nsurance:
_
_Religious/Charitable Contributions:
Clothing
Uniforms:
.~D_ rry Cleaners :
Entertainment:
_Gifts:
Food:
Doctor:
Dentist:
_Orthodontist:
...
Drugs /Medicines: ~
Optometrist/Op hthaImologist/Eyelasses:
Medical/Dental Insurance (not deducted
_ from pay.
_ Life Insurance (not deducted from pay)-
Actual
Antici " ated
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements
from retirement plans, periodic statements reflecting assets held in name of or on behalf of
children, and documents reflecting debts and credit card statements for past 12 months
should be in possession of answering party or answering party's attorney when this
statement is served on the opposing party.
American LegalNet, Inc.
www.USCourtForms.com
Anticipated
Actual
Disability Insurance (not deducted from
pay):
_News " . " er:
a6ptions:
Mag
Veterinarian/Pet Food:
Professional Dues/Club Membersh
Social Clubs :
_
Barber/Beauty Shop:
Tuition/School Expenses:
State/Federal/Local Taxes Not Withh eld_
:
child _
_ Child support paid for prior born
e
Child su~ r_ " "
Maintenance pro" ' "rax"a--V~ouse
" ouse
Maintenance " _ ' " _
Athletic and Activity Fees list
Debt payments list
Other Monthly Expenses list
TOTAL MONTH LY EXPENSES
_
$
$
0 Petitioner 0 Respondent states that the above information is true and correct to the
best of my knowledge and belief, and that it results from a diligent, good faith effort to
ascertain the information sought herein, based upon information and documents available
to me and/or within my possession or control . All documents upon which this information is
based and the documents requested herein have been produced and are currently in the
office of my counsel .
0 Petitioner 0 Respondent
American LegalNet, Inc.
www.USCourtForms.com
STATE OF KENTUCKY
)
COUNTY OF
)
the
SCT.
on this
Subscribed and sworn to before me by
day of
,
My commission expires :
Notary Public,
CERTIFICATE OF SERVICE
This is to certify that the foregoing Preliminary Verified Disclosure Statement was 0
day
mailed 0 hand-delivered to counsel for 0 Petitioner 0 Respondent on this the
and supporting the
of
, and documents requested
information set forth herein are currently available at the undersigned's office or are in the
undersigned's possession and are available for inspection and copying at the requesting
party's expense .
ATTORNEY FOR 0 PETITIONER 0 RESPONDENT
or 0 PETITIONER 0 RESPONDENT
American LegalNet, Inc.
www.USCourtForms.com
