IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. Plaintiff(s) Defendant(s) File Stamp COMPREHENSIVE FINANCIAL STATEMENT PURSUANT TO LOCAL RULE #15.13 (c) INSTRUCTIONS (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) Use additional sheets if necessary. (3) Attach copies of all supporting documentation in your possession. Petitioner/Respondent, , being duly sworn, states that the following is an accurate 12/6/08 statement as of , of his/her net worth (assets of both parties), 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: Name: Address: Telephone No.: Social Security No. (last 4 digits only): Date of Birth: Date of Dissolution of Marriage: (if applicable) Date of Marriage: Date of Separation: Children of this marriage: age age age age residing with residing with residing with residing with Current Employer: Self Employment: Other Employment: Address: Address: Address: Check if unemployed Number of Paychecks per year (Please Select One) 12 24 26 52 Other Number of Exemptions Claimed: Number of Dependents: Gross income from all sources last year: Gross income from all sources this year: P2-D-034 (11/08) Page 1 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. STATEMENT OF INCOME as of GROSS MONTHLY INCOME Salary/wages/base pay Line 1 Overtime/commission Line 2 Bonus Line 3 Draw Line 4 Pension and retirement benefits Line 5 Annuity Line 6 Interest income Line 7 Dividend income Line 8 Trust income Line 9 Social Security Payments Line 10 Unemployment benefits Line 11 Disability payments Line 12 Worker's Compensation Line 13 Public Aid/Food Stamps Line 14 Investment income Line 15 Rental income Line 16 Business income Line 17 Partnership income Line 18 Royalty income Line 19 Fellowships/stipends Line 20 Other income (specify) Line 21 SUBTOTAL GROSS MONTHLY INCOME (Total of lines 1-21) Line 22 Additional Cash Flow (monthly) Maintenance received Line 23 (payments received prior to judgment or support orders in other actions) Child support received Line 24 (payments received pursuant to Court order or voluntarily in this or other actions) Line 25 SUBTOTAL ADDITIONAL CASH FLOW (Total of line 23 and 24) TOTAL MONTHLY GROSS INCOME FROM ALL SOURCES (Total of line 22 and 25) P2-D-034 (11/08) Line 26 Page 2 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. REQUIRED MONTHLY DEDUCTIONS Federal Tax (based on exemptions) Line 27 State Tax (based on exemptions) FICA (or Social Security equivalent) Line 28 Line 29 Medicare Tax Line 30 Mandatory retirement contributions required by law or as conditions of employment Line 31 ) Line 32 Union Dues (Name of Union Health/Hospitalization Premiums Line 33 Prior obligation(s) of support actually paid pursuant to Court Order Line 34 TOTAL REQUIRED DEDUCTIONS FROM MONTHLY INCOME (Add lines 27 through 34) Line 35 $0.00 Line 36 NET MONTHLY INCOME (Line 26 minus line 35) STATEMENT OF MONTHLY LIVING EXPENSES as of 1. Household a. Mortgage or rent (specify) Line 37 b. Home equity loan/Second mortgage Line 38 c. Real estate taxes, assessments Line 39 d. Homeowners or renters insurance Line 40 e. Heat/fuel Line 41 f. Electricity Line 42 g. Telephone (include long distance and cell) Line 43 h. Water and Sewer Line 44 i. Refuse removal Line 45 j. Laundry/dry cleaning Line 46 k. Maid/cleaning service Line 47 l. Furniture and appliance repair/replacement Line 48 m. Lawn and garden/snow removal Line 49 n. Food (groceries, household supplies, etc.) Line 50 o. Liquor, beer, wine, etc. Line 51 p. Cable/Satellite/Internet Line 52 q. Other (specify) Line 53 SUBTOTAL HOUSEHOLD EXPENSES (Total of lines 37 through 53) Line 54 P2-D-034 (11/08) Page 3 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. MONTHLY LIVING EXPENSES CONTINUED 2. Transportation a. Gasoline Line 55 b. Repairs Line 56 c. Insurance/license/city stickers Line 57 d. Payments/replacement Line 58 e. Alternative transportation Line 59 f. Other (specify) Line 60 SUBTOTAL TRANSPORTATION EXPENSES Line 61 (Total of line 55 through 60 3. Personal a. Clothing Line 62 b. Grooming Line 63 c. Medical (after insurance) 1. Doctor Line 64 2. Dentist Line 65 3. Optical Line 66 4. Medication d. Insurance Line 67 1. Life Insurance Premiums Line 68 2. Medical/Hospitalization Insurance Premiums Line 69 3. Dental/Optical Insurance Premiums Line 70 e. Other (specify) Line 71 SUBTOTAL PERSONAL EXPENSES Line 72 (Total of line 62 through 71 4. Miscellaneous a. Clubs/social obligations/entertainment Line 73 b. Newspaper, magazines, books Line 74 c. Gifts Line 75 d. Donations, church or religious affiliation Line 76 e. Vacations Line 77 f. Other (specify) Line 78 SUBTOTAL MISCELLANEOUS EXPENSES Line 79 (Total of line 73 through 78) P2-D-034 (11/08) Page 4 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. MONTHLY LIVING EXPENSES CONTINUED 5. Dependent children: Name Names and Ages Age Children's separate expenses a. Clothing Line 80 b. Grooming Line 81 c. Education 1. Tuition Line 82 2. Books/fees Line 83 3. Lunches Line 84 4. Transportation Line 85 5. Activities d. Medical (after insurance): Line 86 1. Doctor Line 87 2. Dentist Line 88 3. Optical Line 89 4. Medication Line 90 e. Allowance Line 91 f. Child care/after school care Line 92 g. Sitters Line 93 h. Lessons and supplies Line 94 i. Clubs/summer camps Line 95 j. Vacation Line 96 k. Entertainment Line 97 l. Other (specify) Line 98 SUBTOTAL CHILDREN'S EXPENSES: Line 99 (Total of line 80 through 98) Line 100 TOTAL MONTHLY LIVING EXPENSES: (Add lines 54, 61, 72, 79 and 99) P2-D-034 (11/08) Page 5 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. STATEMENT OF CURRENT DEBTS/LIABILITIES (not previously listed on pages 1-5) Creditor's Name Purpose of Debt Balance Due Monthly Debt Service Monthly Payment $.00 Line 101 $.00 RECAP $.00 Line 102 NET MONTHLY INCOME (Line 36) TOTAL MONTHLY LIVING EXPENSES (Line 100) Line 103 LESS MONTHLY DEBT SERVICE (Line 101) $.00 Line 104 $.00 Line 105 INCOME AVAILABLE PER MONTH (Line 104 minus 105) $.00 Line 106 DIFFERENCE BETWEEN NET INCOME AND EXPENSES (Line 102 minus 103) STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective Health Insurance Coverage: Yes No Name of Insurance Carrier: Type of Insurance: Policy or Group No. Medical Dental Deductible: Per Individual Persons covered: Self Type of policy: HMO Provided by: Employer Optical Per Family Spouse PPO Dependents Standard Indemnity (i.e. 80/20) Private Policy Monthly Cost: Paid by Employer Other Group Paid by Employee For dependents For myself POTENTIAL DEBTS/LIABILITIES Creditor's Name Purpose of Debt Anticipated Debt Anticipated Monthly Payment Cash or Cash Equivalents: 1. Savings or Interest Bearing Accounts Name of Bank and Account Number Title in name of Date Acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount 2. Checking Accounts Name of Bank and Account Number 3. Certificate of Deposit Name of Bank and Account Number P2-D-034 (11/08) Page 6 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. 4. Money Market Accounts Name of Bank and Account Number Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount Title in name of Date acquired Value/Amount 5. Cash Name of Bank and Account Number 6. Other (specify) Name of Bank and Account Number INVESTMENT ACCOUNTS AND SECURITIES: 1. Stocks Description 2. Bonds Description 3. Tax Exempt Securities Description 4. Secured or Unsecured Notes Description 5. Mutual Funds or Brokerage Accounts Description 6. Other (specify) Description P2-D-034 (11/08) Page 7 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. SAFE DEPOSIT BOX: Name of Bank, City, Box Number Keyholder Contents Date acquired Value/Amount REAL PROPERTY: 1. Residence Address of Property Title Holder Date acquired Mortgage Mortgage Amt. Lien Holder(s) Remaining Fair Market Value Title Holder Date acquired Mortgage Mortgage Amt. Lien Holder(s) Remaining Fair Market Value Title Holder Date acquired Mortgage Mortgage Amt. Lien Holder(s) Remaining Fair Market Value Title Holder Date acquired Mortgage Mortgage Amt. Lien Holder(s) Remaining Fair Market Value Title Holder Date acquired 2. Secondary or vacation residence Address of Property 3. Investment or Business Real Estate Address of Property 4. Vacant Land Address of Property 5. Other (specify) Address of Property Mortgage Lien Holder Mortgage Amt. Remaining Fair Market Value Value Loan Balance % Interest/ # of Shares Value/Amount MOTOR VEHICLE(S), BOAT(S), TRAILER(S), ETC. Year, Make, Model Title in name of Date acquired Lien Holder(s) BUSINESS INTERESTS: Type of entity, i.e. Corporations, Partnerships, Sole Proprietorships Business Name/Type of Business In name of Date acquired INSURANCE POLICIES: Type of insurance, i.e. Life, Medical, Disability, Business Overhead, Property, etc Name of Company/Policy Number P2-D-034 (11/08) Name of insured Date acquired Beneficiary Value/Amount Page 8 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. RETIREMENT, PENSION PLANS, IRA ACCOUNTS, DEFERRED COMPENSATION, ANNUITIES, 401(k), PROFIT SHARING, etc.: Name of Company/Type of Plan Participant Vested Date acquired Beneficiary Value/Amount Y/N STOCK OPTIONS, ESOPs, OTHER DEFERRED COMPENSATION OR EMPLOYMENT BENEFITS: (Describe fully) Description Title in name of Date acquired Fair Market Value Tax Year(s) Refund Amount INCOME TAX REFUNDS: Federal and State (current or expected) Federal/State/Taxpayer Name Joint or Individual PENDING CLAIMS FOR PERSONAL INJURY, WORKER'S COMPENSATION, BANKRUPTCY, OR OTHER LAWSUITS, CLAIMS AND/OR DEMANDS SEEKING MONETARY AWARD(S) OR OTHER RELIEF: Claimant Nature and Amount of Claim Date of Name and Address of Attorney Occurrence COLLECTIBLES: Coins, stamps, art, antiques, etc. Description Title in name of Date acquired Value/Amount ALL OTHER MARITAL PROPERTY: Personal or Real, NOT PREVIOUSLY LISTED, valued in excess of $500.00 excluding normal household furniture and furnishings) Description Title in name of Date acquired Fair Market Value NONMARITAL PROPERTY: Identify all property claimed to be nonmarital Description Title Date acquired Inheritance(I) or Gift(G) Premarital (P) Value/ Amount STATEMENT OF ASSET TRANSFERRED: (List all assets transferred in any manner during the preceding six (6) months) Description of Property P2-D-034 (11/08) To Whom Transferred and Relationship To Transferee Date of Transfer and Purpose Value/ Amount Page 9 of 10 American LegalNet, Inc. www.FormsWorkflow.com COMPREHENSIVE FINANCIAL STATEMENT (CONT) Case No. CERTIFICATE OF DOCUMENT PRODUCTION I, , certify that the attached document(s) are all of the documents I have in my possession or that I can obtain upon reasonable effort as of this date. The undersigned certifies that he/she has read the above and foregoing Comprehensive Financial Statement; that he/she knows the contents thereof, and that the information therein contained is true and correct. I have provided copies of all supporting documents in my possession, relating to the disclosures made above. Signature of Party Petitioner Respondent Type or Print Name P2-D-034 (11/08) Page 10 of 10 American LegalNet, Inc. www.FormsWorkflow.com