2800 - Affidavit 3558 - Disclosure Statement Filed 3128 - Answer to Asset/Financial Disclosure Statement Filed Disclosure Statement Print Form Clear Form (Rev. 1/22/09) CCDR 0604 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - DOMESTIC RELATIONS DIVISION IN RE The Marriage Support Custody Parentage ____________________________________________________, Petitioner, and ____________________________________________________, Respondent. STATE OF _______________________ COUNTY OF _____________________ } } No. ______________________________________ Calendar: _________________________________ DISCLOSURE STATEMENT (Pursuant to Rule 13.3.1) ss: Petitioner/Respondent, ______________________________________, being duly sworn, deposes and says that the following is an accurate statement as of __________________________, _________, of my net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), statement of income from all sources, statement of monthly living expenses, statement of health insurance coverage, and statement of assets transferred of whatsoever kind and nature and wherever situated: Name: ____________________________________________ Telephone No.: __________________________________________ Address: __________________________________________ Date of Birth: ______________________________________________ __________________________________________________ Date of Dissolution of Marriage: ____________________________ (if applicable) Date of Marriage: __________________________________ Parties reside in the same household: Yes Minor and/or Dependent Children of this Full Names No Marriage or Parentage Age DOB Residing with ________________________________________ ________ ____________ _______________________________________ ________________________________________ ________ ____________ _______________________________________ ________________________________________ ________ ____________ _______________________________________ Current Employer: _______________________________________ Address: _________________________________________________ Self Employment: ________________________________________ Address: ________________________________________________ Other Employment: ______________________________________ Address: ___________________________________________________ Check if unemployed Number of Paychecks per year Number of Exemptions claimed: __________ 12 24 26 52 Number of Dependents claimed: __________ Gross income from all sources last year: __________________________________________________________________________________ Gross income from all sources this year through: __________________________________________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 1/22/09) CCDR 0604 B Case No. __________________________ STATEMENT OF INCOME as of _____________________________ Gross Monthly Income Salary/wages/base pay $ __________________________ __________________________ Overtime/commission __________________________ Bonus __________________________ Draw __________________________ Pension and retirement benefits __________________________ Annuity __________________________ Interest income __________________________ Dividend income __________________________ Trust income __________________________ Social Security __________________________ Unemployment benefits __________________________ Disability payment __________________________ Worker's compensation __________________________ Public Aid/Food stamps __________________________ Investment income __________________________ Rental income __________________________ Business income __________________________ Partnership income __________________________ Royalty income __________________________ Fellowship/stipends __________________________ Other income (specify): ______________________________________________________ 0.00 $ ______________________ TOTAL GROSS MONTHLY INCOME Required Monthly Deductions Federal Tax (based on _________ exemptions) State Tax (based on __________ exemptions) FICA (or Social Security equivalent) Medicare Tax Mandatory retirement contributions required by law or as condition of employment Union Dues (Name of Union: _______________________) Health/Hospitalization Premiums Prior obligation(s) of support actually paid pursuant to Court order Expenditures for repayment of debts that represent reasonable and necessary expenses for the production of income (identify and itemize) Medical expenditures necessary to preserve life or health Reasonable expenditures for the benefit of the child and the other parent exclusive of gifts (for non-custodial parent only) $ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ (identify and itemize on a separate sheet) TOTAL REQUIRED DEDUCTIONS FROM INCOME NET MONTHLY INCOME 0.00 $ _______________________ $ _______________________ (Rev. 1/22/09) CCDR 0604 C Case No. _________________________ STATEMENT OF MONTHLY LIVING EXPENSES as of ____________________________ 1. Household $ ____________________________ a. Mortgage or rent (specify) b. Home equity payment ____________________________ c. Real estate taxes, assessments ____________________________ d. Homeowners or renters insurance ____________________________ e. Heat/fuel ____________________________ f. Electricity ____________________________ g. Telephone (include long distance/cellular/fax or modem lines) ____________________________ h. Water and Sewer ____________________________ i. Refuse removal ____________________________ j. Laundry/dry cleaning ____________________________ k. Maid/cleaning service ____________________________ l. Furniture and appliance repair/replacement ____________________________ m. Repairs and maintenance to dwelling ____________________________ n. Lawn and garden/snow removal ____________________________ o. Food (groceries, household supplies, etc.) ____________________________ p. Liquor, beer, wine, etc. ____________________________ q. Cable/Satellite TV ____________________________ r. Internet Service Provider ____________________________ s. Other (specify): __________________________________________________________ ____________________________ SUBTOTAL HOUSEHOLD EXPENSES: 2. Transportation a. Gasoline $ ____________________________ b. Repairs and Maintenance ____________________________ c. Insurance/license/city stickers ____________________________ d. Payments/replacement ____________________________ e. Alternative transportation ____________________________ f. Parking ____________________________ g. Other (specify): ___________________________________________________________ ____________________________ SUBTOTAL TRANSPORTATION EXPENSES: 3. 0.00 $ _______________________ Personal a. Clothing b. Grooming c. Medical (after insurance proceeds/reimbursement) (1) Doctor (2) Dentist (3) Optical (4) Medication d. Insurance (1) Life (term) (2) Life (whole or annuity) (3) Medical/Hospitalization (4) Dental/Optical e. Other (specify): ____________________________________________________ SUBTOTAL PERSONAL EXPENSES: 0.00 $ _______________________ $ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ __________________________ __________________________ __________________________ __________________________ __________________________ 0.00 $ ________________________ (Rev. 1/22/09) CCDR 0604 D 4. Miscellaneous Case No.___________________________ a. Clubs/social obligations/entertainment (including dining out) $ b. Newspapers, magazines, books c. Gifts d. Donations, church or religious affiliation e. Vacations (not including children) f. Computer/Supplies/Software g. Other (specify): ____________________________________________ 0.00 $ ________________________ SUBTOTAL MISCELLANEOUS EXPENSES: 5. ____________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ Minor and/or Dependent children: a. Clothing b. Grooming c. Education (1) Tuition (2) Books/Fees (3) Lunches (4) Transportation (5) School-sponsored activities d. Medical (after insurance proceeds): (1) Doctor (2) Dentist (3) Optical (4) Medication e. Allowance f. Child care/Pre-school care/After-school care (not included elsewhere) g. Sitters h. Lessons/extracurricular activities/supplies i. Clubs/Summer Camps j. Vacations (children only) k. Other activities l. Entertainment m. Other (specify) (e.g. gifts children give to others) $ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ 0.00 $ ________________________ SUBTOTAL CHILDREN'S EXPENSES: TOTAL MONTHLY LIVING EXPENSES: 0.00 $ ________________________ STATEMENT OF LIABILITIES Note: Identify all creditors, but DO NOT DUPLICATE monthly expense if listed above as monthly expense item. CREDITOR NAME PAYMENT FOR BALANCE DUE MINIMUM MONTHLY PAYMENT _________________________________________ _________________________________________ ______________________ ______________________ $ __________________ ____________________ $ __________________ ____________________ _________________________________________ ______________________ $ __________________ ____________________ _________________________________________ ______________________ $ __________________ ____________________ _________________________________________ ______________________ $ __________________ ____________________ SUBTOTAL MONTHLY DEBT SERVICE: $ ____________________________ (Rev. 1/22/09) CCDR 0604 E Case No.___________________________ RECAPITULATION NET MONTHLY INCOME TOTAL MONTHLY LIVING EXPENSES DIFFERENCE BETWEEN NET INCOME AND EXPENSES LESS MONTHLY DEBT SERVICE INCOME AVAILABLE PER MONTH $ ______________________________ 0.00 ______________________________ 0.00 ______________________________ ______________________________ 0.00 ______________________________ CONTINGENT LIABILITIES: (Provide potential obligor, claimant, basis of claim, date incurred, amount claimed, who incurred.) __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ Have you ever filed for Bankruptcy? Yes No Is so, when? Date ____________________ Case No. ____________________________ Additional Cash Flow (monthly) (Identify but do not add to monthly income) Spousal Support Received (Payments received from prior Judgment or Support orders in other actions): _________________________________ Case No. _________________________________ Child Support Received (Payments received pursuant to Court order in this action): _____________________________ (Payments received pursuant to Court order in other actions): _____________________________ Case No.: _____________________________ STATEMENT OF ASSETS The date of valuation is _______________________________ unless otherwise specified. Please designate values. In prejudgment dissolution of marriage actions, please indicate whether the property is marital (M) or non-marital husband (NMH) or non-marital wife (NMW). Please use Supplemental Statement of Assets (Part I of this form) if more space is needed to complete this section. Description of Asset CASH or CASH EQUIVALENTS: 1. Savings or interest-bearing accounts 2. Checking Accounts 3. Certificates of Deposit 4. Money Market Accounts 5. Cash 6. Other (specify): Title in Name of M/NMH/NMW Value (Rev. 1/22/09) CCDR 0604 F Case No.____________________________ INVESTMENT ACCOUNTS and SECURITIES: 1. Stocks 2. Bonds 3. Tax exempt securities 4. Secured or Unsecured Notes 5. Other (specify): REAL PROPERTY: (Provide address, type and description, amounts of mortgages, loans or liens) 1. Residence 2. Secondary or vacation residence 3. Investment or Business Real Estate 4. Vacant Land 5. Other (specify): MOTOR VEHICLE(s): Boats, Trailers, Etc. (Provide Year, Model, Make, Lien, Debtor, Amount) BUSINESS INTERESTS: Corporations, Partnerships, Sole Proprietorships (Provide percentage interest and number of shares, name of business, type of business, type of entity, current accounts receivable, current bank account balances, current inventory value) INSURANCE POLICIES: Life, medical, disability, business overhead, property, etc. (Provide type of insurance, insurer, policy number, name of insured, owner of policy, face amount, beneficiary, face value, cash value, surrender value, current death benefits) (Rev. 1/22/09) CCDR 0604 G Case No. _____________________________ PENSION PLANS, IRA ACCOUNTS, DEFERRED COMPENSATION, ANNUITIES, 401K, etc.: (Provide name and type of plan, trustee of plan, nature of interest, beneficiary, vested or non-vested, current value) STOCK OPTIONS, ESOPS, OTHER DEFERRED COMPENSATION OR EMPLOYMENT BENEFITS: (Describe fully) INCOME TAX REFUNDS: Federal and State (Identify tax year) CHOSES IN ACTION: (Provide date of occurrence, nature/amount of claim, date suit filed, case number, name of plaintiffs) COLLECTIBLES: (Coins, stamps, art, antiques, etc.) ALL OTHER PROPERTY: (Personal or Real, NOT PREVIOUSLY LISTED valued in excess of $500.00) STATEMENT OF ASSETS TRANSFERRED OR SOLD List all assets transferred or sold in any manner during the preceding three years, or length of marriage, whichever is shorter (transfers or sales in the routine course of business which resulted in an exchange of assets of substantially equivalent value need not be specifically disclosed where such assets are otherwise identified in the statement of net worth.) Description of Property To Whom Transferred or Sold and Relationship to Transferee Date of Transfer Value Amount Received _____________________________ ______________________________ ________________ __________ ______________ _____________________________ ______________________________ ________________ __________ ______________ _____________________________ ______________________________ ________________ __________ ______________ _____________________________ ______________________________ ________________ __________ ______________ _____________________________ ______________________________ ________________ __________ ______________ (Rev. 1/22/09) CCDR 0604 H Case No. ______________________________ STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage? Yes No Name of insurance carrier: _____________________________ Policy or Group No. ___________________ Type of insurance: Medical ‰ Dental Optical Deductible: Per individual ________________________ Per family ______________________ Persons covered: Self Spouse Dependents Type of policy: HMO PPO Full indemnity Provided by: Employer Private Policy Other Group Monthly cost: Paid by employer Paid by employee $ ______________ for dependents per month $ ______________ for myself per month The foregoing Asset Disclosure Statement has been carefully read by the undersigned who states under oath, under penalties as provided by law pursuant to 735 ILCS 5/1-109, that s/he has knowledge of the matters stated and that the statements set forth in this Affidavit are true and correct, except as to matters specifically stated to be on information and belief, and as to such matters the undersigned certifies as aforesaid that s/he believes same to be true. Signature of Party Petitioner Respondent Type or Print Name Signed and sworn to before me _______________________________________, _________. Notary Public DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 1/22/09) CCDR 0604 I Case No. ______________________________ Supplemental Statement of Assets _________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ ________________________________________________________________________________________ _________________________________________________________________________________________ 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