STATE of ______________ ________________ ) ) COUNTY ) IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ____________ COUNTY, ILLINOIS IN RE THE MARRIAGE OF: ______________________________, Petitioner, and ______________________________, Respondent. ) ) ) ) ) ) ) ) NO. ___________ IXb FINANCIAL DISCLOSURE STATEMENT OF PETITIONER/RESPONDENT WIFE HUSBAND Name: Address: Name: Address: No. occupants in household: Employer: Occupation: No. occupants in household: Employer: Occupation: CHILDREN Total number of children of this relationship: Of that total number of children, how many reside with? total mother/wife father/husband Number of other children residing with either parent (Note below) mother/wife father/husband Note: (do not count children of this relationship at issue) STATEMENT OF INCOME, EXPENSES, ASSETS & LIABILITIES INCOME HUSBAND WIFE GROSS MONTHLY INCOME from: Salary, wages, commissions, bonuses, allowances & overtime (Note: To arrive at gross monthly income, multiply weekly gross by 4.3 ............ ............ ............ ............ ............ ............ TOTAL GROSS MONTHLY INCOME $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ if paid weekly, or multiply bi-weekly income by 2.15 if paid bi-weekly.). . . Pension or retirement Social Security benefits Disability or unemployment benefits Public aid (ADC - Welfare) Child support from prior marriage (alimony) Rents Other income (specify) Other income (specify) Other income (specify) $ - - American LegalNet, Inc. www.USCourtForms.com Rule IXb Financial Disclosure 1 revised Jan. 2006 DEDUCTIONS: State income tax withheld ........... Federal income tax withheld ........... Social Security / Medicare withheld (OASDI) . . . . . . . . . . . .................... Medical or other insurance Prior Court Ordered Support Withholding ........... Mandatory Retirement (TRS, IMRF, etc.) ........... Voluntary Retirement (401k, TSP, SIP) ........... .................... Credit Union payments .................... Credit Union savings Union or other dues: (specify) Other deductions (specify) Other deductions (specify) TOTAL MONTHLY DEDUCTIONS HUSBAND $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ WIFE $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ - $ TOTAL NET MONTHLY INCOME $ No. exemptions claimed: Number of paychecks per year: Filing status: monthly (12) single married semi-weekly (24) other (specify below) bi-weekly (26) weekly (52) - $ - EXPENSES LIST ALL EXPENSES BY MONTH: State the name and relationship of all persons whose expenses are included: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Mortgage or rental payments (residence) ................... Real estate taxes if not included in mortgage payment . . . . . . . . . . . . Real estate insurance if not included in mortgage payment . . . . . . . . Food & household supplies ................... Utilities (gas, electric, water, sewer) ................... Home Telephone .................. ................... Cell Phone .................. ................... Internet .................. ................... Laundry & dry cleaning ................... Clothing (for yourself and family members) ................... Medical (expenses not covered by insurance) . . . . . . . . . . . . . . . . . . Dental (expenses not covered by insurance) ................... Insurance ( do not include payroll deducted items) specify health, dental, disability/accident, life, etc) ___________ . . . . Child Care (babysitters, etc.) ................... School (preschool, college, other schooling expenses) ........... Payment of child/spousal support from prior marriage . . . . . . . . . . . . . . Auto expenses (gas, oil, repairs) ................... Auto insurance ................... Auto payments (exclude payroll deducted) ................... Transportation (other than automobile) ................... Entertainment (clubs, movies, recreation, travel, etc) ........... Incidentals (grooming, gifts, etc.) ................... Installment payments (charges, etc., not previously included) Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ TOTAL MONTHLY LIVING EXPENSES $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ - - American LegalNet, Inc. www.USCourtForms.com Rule IXb Financial Disclosure 2 revised Jan. 2006 ASSETS REAL ESTATE: If more than one parcel owned, please attach schedule with following information: Address: Type of property: Date of Purchase: How title held: Mortgage holder Tax amount: ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ $_____________ CERTIFICATES OF DEPOSIT last 4 numbers of cerificate: Where held: _________________________ _________________________ In whose name: Amount: $__________ Maturity Date: _________________________ $__________ Present Value: Original cost: Improvements: Total Costs: $ $ $ - Liens: Present market value: EQUITY:(value - liens) $ $ $ - last 4 numbers of cerificate: Where held: In whose name: Amount: Maturity Date: Present Value: ______________________ ______________________ $__________ ______________________ $__________ CHECKING AND/OR SAVINGS ACCOUNTS: (Include any IRA accounts or money market accounts) Type of Account Owner Present Balance Names of Institution _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ PENSIONS, RETIREMENT PLANS: (Includes IRA's, SIP's, 401K Plans, deferred income & profit sharing) Name of company: Name of company: In whose name: In whose name: How many years employed: How many years employed: Present cash value: $__________ Present cash value: $__________ Name & Address of Plan Administrator: Name & Address of Plan Administrator: STOCKS, BONDS, TREASURY NOTES, BILLS AND OTHER INVESTMENTS: Name of investor: Name of investor: In whose name: In whose name: Present cash value: Present cash value: LIFE INSURANCE AND ANNUITIES: Name of Company: In whose name: Face amount: $__________ Present cash value: $__________ MOTOR VEHICLES: Year Make/Model Name of Company: In whose name: Face amount: Present cash value: How Title held Liens $ $ $ $ $ $__________ $__________ Value $ $ $ $ $ American LegalNet, Inc. www.USCourtForms.com Rule IXb Financial Disclosure 3 revised Jan. 2006 HOUSEHOLD GOODS & FURNISHINGS: (List major items only) ITEM VALUE IN WHOSE POSSESSION _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ ____________________ _____________________________________________________________ $__________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ OTHER ASSETS: (Interest in a Trust, Stock Options, Deferred Compensation, ATV's, motorcycles, boats, machinery, tools, pending worker's compensation, personal injury or other litigation or collection claims, etc.) ITEM VALUE IN WHOSE POSSESSION _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ BUSINESS / FARMING INTERESTS: (List interest in any business, corporation, farms, etc. which you or your spouse have an ownership interest in.) Name of Business: Form of Ownership: Nature of Business Interest (explain): Name of Company Value: DEBTS & LIABILITIES For Balance $ $ $ $ $ $ $ $__________ Monthly Payment $ $ $ $ $ $ $ NON-MARITAL PROPERTY CLAIMED BY YOU: (Owned before marriage, gift or inheritance) Item Value Basis of Claim _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ PREMARITAL AGREEMENT? HEALTH INSURANCE COVERAGE Health insurance coverage currently in effect? Name of insurance carrier: medical Type of insurance: optical per individual Deductible: self Persons covered: employer Provided by: Monthly costs for: $________ self employer cost paid by: employee's contribution: $___________ Rule IXb Financial Disclosure yes no yes no dental prescription per family dependents private policy $___________ dependents employee COBRA cost: 4 American LegalNet, Inc. www.USCourtForms.com spouse $___________ revised Jan. 2006 I, the undersigned, declare under penalty of perjury that the foregoing, including attachments, is a true and correct declaration of my assets and liabilities, and that I executed this on the day of 20 . _______________________________ Signature SUBSCRIBED AND SWORN to before me this . day of NOTARY PUBLIC American LegalNet, Inc. www.USCourtForms.com Rule IXb Financial Disclosure 5 revised Jan. 2006