Statement Of Income Assets Debts And Living Expenses

FORM SUMMARY Name of Form: Statement of Income, Assets, Debts and Living Expenses Form Number: JD-1718 Statutory Reference: Chapters 48 and 938. Benchbook Reference: JV 6, 8, & 11 Purpose of Form: To provide financial information to the court. This form is always used when it appears that a child/juvenile may be placed outside of his or her home in a court proceeding but can also be used whenever it is appropriate to have a determination of a parent's financial status. Who Completes It: Parents of a child/juvenile. Distribution of Form: Original provided to parents to complete. Parents return the original to the court. Accompanying Forms: JD-1717 (Order to provide statement of income, assets, debts and living expenses) initiates and always accompanies this form. New Form/Modification: Modification, last update 06/03. Modifications: Added telephone number. Comments: If it appears that a child/juvenile may be placed outside of the home as a result of a dispositional order, or if there is a request to change the placement of a child/juvenile to outside the home, the court is required to have the parents complete a statement of income, assets, debts and living expenses. The court is then required to enter a support order to help cover the costs of out-of-home placements. The statutes indicate that the completed statement is to be returned to either the court or the agency responsible for implementation of the court order. RMC decided to have the standard order (see JD-1718) default to sending the completed form to the court with the court having the option to also require sending it to the agency. About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 08/07/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, Statement of Income, Assets, Debts and Living Expenses IN THE INTEREST OF Name Case No. Date of Birth Under penalty of perjury, I state that the following information on this financial statement is true, accurate and complete: Print Name of Person Completing Form Name of Father's Employer Number of People in Household Name of Mother's Employer Adults Children STATEMENT OF MONTHLY HOUSEHOLD INCOME (If there are insufficient columns for all household members, attach additional schedules.) Father Mother Other Household 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 Fair Market/ Cash Value Description 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, 08/07 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 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Statement of Income, Assets, Debts and Living Expenses Page 2 of 2 Case No. LONG TERM DEBTS AND MONTHLY EXPENSES Long Term/Installment Debts Balance Owed Creditor Name 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 Signature Complete this form and return it to the juvenile court clerk so that it arrives by the time indicated on the court order. Telephone Number Date Signed JD-1718, 08/07 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 American LegalNet, Inc. www.FormsWorkflow.com