COMPREHENSIVE FINANCIAL STATEMENT STATE OF ILLINOIS 3417 (Rev. 03/2011 UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT COUNTY OF DU PAGE IN RE: THE MARRIAGE OF PLAINTIFF CASE NUMBER vs COMPREHENSIVE FINANCIAL STATEMENT INSTRUCTIONS RESPONDENT (pursuant to Local Rule 15.01.3) File Stamp Here 1. All questions require a written response. If you do not have the information requested or do not know the answer to a particular question, indicate that as your answer. 2. Petitioner / Respondent, being duly sworn, states that the following is an accurate statement as of of their net worth (assets of whatsoever kind and nature and wherever situated minus liabilities), a statement of income from all sources, a statement of monthly living expenses, a statement of health insurance coverage, and a statement of assets transferred of whatsoever kind and nature and wherever situated: (Use additional sheets if necessary) , I. General Information Name Telephone No. Address Social Security No. Driver's License No. Date of Birth Date of Marriage Date of Separation Date of Dissolution of Marriage (if applicable) Children of this Marriage (Use additional sheets if necessary) Date of Birth residing with Date of Birth residing with Date of Birth residing with Employment Current Employer Address Self Employment Address Other Employment Unemployed Address Number of Pay Checks per year 12 Number of Exemptions Claimed 24 26 52 Other Number of Dependents Gross income from all sources last year Gross income from all sources this year through CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 1 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. II. Statement of Current Income Gross Monthly Income Salary / Wages / Base Pay Overtime / commission Cash Bonus Stock Bonus Draw Pension and Retirement Benefits Annuity Interest Income Dividend Income Trust Income Social Security Payments Unemployment Benefits Disability Payments Workers' Compensation Public Aid / Food Stamps Investment Income Rental Income Business Income Partnership / Sub-Chapter, or LLC Income Royalty Income Other Income Total Monthly Gross Income From all Stock Voluntary Deductions from Income Total Voluntary Deductions Required Monthly Deductions Federal Tax (based on exemptions) State Tax exemptions) (based on FICA or Social Security equivalent Medicare Tax CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 2 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. II. Statement of Current Income continued Mandatory retirement contribution 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 Total Required Deductions III. Statement of Current Monthly Living Expenses 1. Household Mortgage or Rent (specify) Home equity loan / Second Mortgage Real Estate Taxes, Assessments Homeowners or Renters Insurance Heat / Fuel Electricity Telephone (include long distance) Water and Sewer & Refuse Removal Laundry / Dry Cleaning Maid / Cleaning Service Furniture & Appliance Repair / Replacement Lawn & Garden / Snow Removal Food (groceries, liquor, household supplies etc) Other (specify) Subtotal Household Expenses 2. Transportation Gasoline Repairs Insurance / License / City Stickers Payments / Replacement Alternate Transportation Other (specify) Subtotal Transportation Expenses 3. Personal Clothing Grooming CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 3 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. III. Statement of Current Monthly Living Expenses continued 3. Personal continued Medical (after insurance proceeds) Doctor Dentist Optical Medication Insurance Life Insurance Premiums Medical / Hospitalization Insurance Premiums Dental / Optical Insurance Premiums Other (specify) Subtotal Personal Expenses 4. Miscellaneous Clubs / social Obligations / Entertainment Newspapers, Magazines, Books Gifts Donations, Church, or Religious Affiliation Vacations Other (specify) Subtotal Miscellaneous Expenses 5. Dependent Children (Name and Ages) CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 4 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. III. Statement of Current Monthly Living Expenses continued 5. Dependent Children (Name and Ages) continued Children's Separate Expenses Clothing Grooming Education Tuition Books / Fees Lunches Transportation Activities Medical (after insurance proceeds) Doctor Dentist Optical Medication Allowance Child Care / After School Care Sitters Lessons and Supplies Clubs / Summer Camps Vacation Entertainment Other (specify) Subtotal Children's Expenses TOTAL MONTHLY LIVING EXPENSES CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 5 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. Recap Net Monthly Income $ Total Monthly Living Expenses $ Difference Between Net Income and Expenses $ Less Monthly Debt Service $ Income Available per Month $ IV. Statement of Health Insurance Coverage Currently Effective Health Insurance Coverage Name of Insurance Carrier Yes No Policy or Group No. Type of Insurance Medical Dental Optical Persons Covered Self Spouse Dependents Type of Policy HMO PPO Standard Indemnity (i.e.80/20) Provided by Employer Private Policy Other Group Deductible Per Individual Per Family Monthly Cost Paid by Employer Paid by Employee For Dependents Paid Myself CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 6 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. V. Statement of Debts / Liabilities Creditor's Name Purpose of Debt Balance Due Monthly Payment Contingent Debts / Liabilities Provide name of potential obligor / creditor; claimant; basis of claim; date occurred; amount claimed; who incurred Name of Potential of Obligor / Creditor Claimant Basis of Claim Date Incurred Amount Claimed CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 Who Incurred PAGE 7 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 VI. Statement of Assets The date of valuation is Description of Asset Title in Name of unless specified. Date Aquired Inheritance (I) or Gift (G) I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I Cash or Cash Equivalents Fair Market Value G 1. Savings or Interest Bearing Accounts 2. Checking Accounts 3. Certificates of Deposit 4. Money Market Accounts 5. Cash 6. Other (specify) CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 8 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. VI. Statement of Assets continued Description of Asset Title in Name of Date Aquired Inheritance (I) or Gift (G) I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I Fair Market Value G Investments Accounts and Securities 1. Stocks 2. Bonds 3. Tax Exempt Securities 4. Secured or Unsecured Notes 5. Other (specify) Safe Deposit Box Provide name of bank; description of contents CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 9 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. VI. Statement of Assets continued Real Property Provide address; type and description; current fair market value; amounts of mortgages; loans or liens 1. Residence I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G I G 2. Secondary or Vacation Residence 3. Investment or Business Real Estate 4. Vacant Land 5. Other (specify) Motor Vehicle(s), Boats, Trailer etc. Provide year, model, make, lien, debtor, amount CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 10 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. VI. Statement of Assets continued Business Interests Provide type of entity, i.e. corporations, partnerships, sole proprietorships. Provide percentage interest and number of shares, name of business, type of business. I G I G I G Insurance Policies Provide type of insurance; i.e. life, medical disability, business overhead, property etc. Provide name of insurer, policy number, name of insured, owner of policy, face amount, beneficiary, cash value, cash surrender value. I G I G I G Retirement, Pension Plans, IRA Accounts, Deferred Compensation, Annuities, 401 (k), Profit Sharing, etc. Provide type and name of plan, trustee of plan, beneficiary vested or non-vested, most current value I G I G I G I G I G I G Stock Options, ESOP's, Other Deferred Compensation or Employment Benefits Describe fully Pending Claims for Personal Injury, Worker's Compensation or other Lawsuits Seeking Monetary Award Provide date of occurrence, nature and amount of claim, date lawsuit filed, case number, name of plaintiffs, name and address of attorney representing you I G I G I G I G I G I G Collectibles Coins, stamps, art, antiques, etc. CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 11 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. VI. Statement of Assets continued All Other Property Personal or Real -- Not Previously Listed -- valued in excess of $500.00, excluding normal household furniture and furnishings I G I G I G I G I G I G VII. Statement of Assets Transferred List all assets transferred in any manner during the preceding six (6) months Description of Property To Whom Transferred and Relationship to Transferee Date of Transfer Value VIII. Non Marital Assets List all non marital property claimed by you, identifying each item of property as to the type of property, date received, the basis on which you claim it is non marital property, and the present value of the property CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 12 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com COMPREHENSIVE FINANCIAL STATEMENT COMPREHENSIVE FINANCIAL STATEMENT 3417 (Rev. 03/2011 Case No. IX. Witnesses A. Pursuant to Illinois Supreme Court Rule 213(f), provide the name and address of each witness who will testify at trial and state the subject of each witness' testimony. B. Pursuant to Illinois Supreme Court Rule 213(g), provide the name and address of each opinion witness who will offer any testimony. (a) State the subject matter on which the opinion witness is expected to testify: (b) State the conclusion and / or opinions of the opinion witness and the basis therefore, including reports of the witness if any: (c) State the qualifications of each opinion witness including a curriculum vitae and / or resume, if any: (d) State the identity of any written reports of the opinion witness regarding the occurrence: X. Physical and Mental Status Are you in any manner incapacitated or limited in your ability to earn income at the present time? If so, define and describe such incapacity or limitation, and state when such incapacity or limitation commenced and when it is expected to end: Certificate of Document Production I, certify that the attached corroborating documents are all the documents I have in my possession or that I can obtain upon reasonable effort as of this date. The undersigned certifies that they have read the above and foregoing Comprehensive Financial Statement; that they know the contents thereof, and that the information therein contained is true and correct. Signature of Petitioner Type or print name Respondent CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60187-0707 PAGE 13 OF 13 American LegalNet, Inc. www.FormsWorkFlow.com