STATE OF ILLINOIS ss COUNTY OF ST CLAIR IN THE CIRCUIT COURT TWENTIETH JUDICIAL CIRCUIT COURT ST CLAIR COUNTY, ILLINOIS IN RE THE [ ] Marriage [ ] Civil Union [ ] Parentage of (check one) _______________________________________________, Petitioner, Case No. _______________ vs _______________________________________________, Respondent FINANCIAL DISCLOSURE STATEMENT PURSUANT TO LOCAL COURT RULE 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) you must attach copies of the following: L Your personal federal and state income tax returns (including all W-2, 1099 and supporting schedules) for the last three (3) calendar years; and L Your most current pay stub. (3) Use additional sheets if necessary. Petitioner/Respondent, ______________________________, under oath, states 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, a statement of health insurance coverage, and statement of assets transferred of whatsoever kind and nature and wherever situated to whomever: Financial Disclosure Statement Pursuant to Local Court Rule Page 1 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ I. Date: _________________________ GENERAL INFORMATION Name: _________________________________________ Telephone No: ________________________ Address: _______________________________________ Date of Birth: _________________________ _______________________________________ Current Age: _________________________ Date of Marriage/Civil Union: ______________________ Reside in same household? [ ] Yes [ ] No Date of Separation: ______________________________ Minor and/or dependent children of this [ ] marriage [ ] civil union or [ ] parentage. (check one) Full Names: Age: Birth date: Residing with: _____________________________ __________ _______________ ________________________ _____________________________ __________ _______________ ________________________ _____________________________ __________ _______________ ________________________ _____________________________ __________ _______________ ________________________ Current Employer: ______________________________ Address _______________________________ Self Employment or other source: __________________ Address _______________________________ Other Employment: _____________________________ Address _______________________________ Other income other than employment: ______________________________________________________ [ ] Check if unemployed Number of Paychecks per Year (check one) [ ] 12 [ ] 24 [ ] 26 [ ] 52 [ ] Other: __________ Number of Exemptions Claimed: __________ Gross Income from all sources for the prior year: ____________________ Gross Income from all sources this year through today: ____________________ Financial Disclosure Statement Pursuant to Local Court Rule Page 2 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ II. Date: _________________________ STATEMENT OF HEALTH INSURANCE COVERAGE Currently effective health insurance coverage: [ ] Yes [ ] No Name of insurance carrier: ______________________ Name of Policy Holder: ____________________ Policy or Group No. _______________________ Type of insurance: [ ] Medical [ ] Dental [ ] Optical Health Savings Account? [ ] Yes [ ] No Pre-Tax? [ ] Yes [ ] No Deductible: Per Individual ____________________ Per Family ____________________ Persons covered: [ ] Self [ ] Spouse/Partner [ ] Dependents Type of policy: [ ] HMO [ ] PPO [ ] Standard Indemnity (i.e. 8-/20) Provided by: [ ] Employer [ ] Private Policy [ ] Other Group Monthly cost: [ ] Paid by Employer or Union Cost to Employee: _______________ for dependents _______________ for self III. [ ] Paid by Employee POTENTIAL AREAS OF DISAGREEMENT (Check all that may apply. The failure to identify an issue shall not be a bar to raising the issue at a later date). [ ] Grounds [ ] Custody [ ] Responsibility for debts [ ] Visitation [ ] Dissipation of marital estate [ ] Child Support/Daycare/Extracurricular [ ] Maintenance [ ] Responsibility for health insurance costs [ ] Tax liabilities [ ] Removal from Illinois [ ] Other: __________________________ [ ] College [ ] Other: __________________________ [ ] Asset identification IV. [ ] Asset values [ ] Other: __________________________ STATEMENT OF ASSETS ACQUIRED DURING MARRIAGE/CIVIL UNION. The date of valuation is ____________, unless otherwise specified. Attach current statements to show the current balance. Financial Disclosure Statement Pursuant to Local Court Rule Page 3 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ Cash or Cash Equivalents: Description of Asset Title in Name of Date Acquired Name of Financial Institution Fair Market Value 1. Savings or Interest Bearing Accounts 2. Checking Accounts 3. Certificates of Deposit 4. Money Market Accounts 5. Cash 6. Other (specify) Real Property: Provide address, type and description, current fair market value, amounts of mortgages, loans or liens. Description of Asset Title in Name of Date Acquired Mortgage Balance Fair Market Value 1. Primary Residence Financial Disclosure Statement Pursuant to Local Court Rule Page 4 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ 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, maker, lien, debtor, amount. Description of Asset Title in Name of (include lien holder, if any) Date Acquired Lien Balance Fair Market Value Business Interests: Type of entity, i.e. Corporations, Partnerships, Sole Proprietorships (Provide percentage interest and number of shares, name of business, type of business.) Name of Entity Owner & Percentage Ownership Date Acquired Type of Business Fair market Value 0% 0% 0% Financial Disclosure Statement Pursuant to Local Court Rule Page 5 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ Insurance Policies: Type of Insurance, i.e. Life, Medical, Disability, Business Overhead, Property, etc. Provide name of insurer, policy number, name of insured, owner of policy, fact amount, beneficiary, cash value, cash surrender value. Name of Insurance Carrier Title in Name of Term or Whole? Death Benefit Actual Case Value Whole Whole Retirement, Pension/Defined Benefit Plans, IRA Accounts, Deferred Compensation, Annuities, 401(k)/Defined Contribution Plan, Profit Sharing, etc: Provide name and type of plan, trustee of plan, beneficiary, vested or non-vested, most current value. Description of Asset Title in Name of Date Acquired Name of Financial Institution Fair Market Value Stock Options, ESOPs, Other Deferred Compensation or Employment Benefits: (Describe fully) Description of Asset Title in Name of Date Acquired Number of Options Option Price Date Acquired Name of Financial Institution Fair Market Value Other Investment Accounts and Securities: Description of Asset Title in Name of 1. Stocks Financial Disclosure Statement Pursuant to Local Court Rule Page 6 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ 2. Bonds 3. Tax Exempt Securities 4. Secured or Unsecured Notes 5. Collectibles: Coins, stamps, art, antiques, etc 6. All Other Property: Personal or Real, (not previously listed), valued in excess of $500.00, excluding normal household furniture and furnishings. V. 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 Financial Disclosure Statement Pursuant to Local Court Rule Date of Transfer Value Page 7 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ VI. STATEMENT OF ASSETS CLAIMED TO BE NON-MARITAL AS DEFINED BY STATUTE. List all property and your basis for claiming it as non-marital (property owned prior to the marriage/civil union, property received as inheritance or gift during the marriage/civil union), identifying each item of property (real property, personal property, financial accounts, etc.) as to the type of property, the date received, the basis on which you claim it is non-marital property, its location, and the present value of property: Description of Asset VII. Date: _________________________ Fair Market Value Basis for Non-Marital Claim (inheritance, gift or other) When Acquired Title Held in Name of STATEMENT OF Debts/LIABILITIES. Include all contingent debts/liabilities. Creditor Name Payment for TOTAL LIABILITIES Attorney Name Who incurred Balance due Minimum monthly payment $0.00 Amount Paid $0.00 Amount Due Petitioner Respondent GAL Have you ever filed for bankruptcy relief? [ ] Yes [ ] No If yes, when? _________ Case No. _________ Financial Disclosure Statement Pursuant to Local Court Rule Page 8 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ VIII. Date: _________________________ SPECIFIC REQUEST OF PERSONAL PROPERTY. (List items requested) _____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ IX. 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 limitations, and state when such incapacity or limitation commenced and when it is expected to end. _____________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ AFFIDAVIT OF INCOME AND EXPENSES CURRENT MONTHLY INCOME OF ________________________ Salary/wages/base pay Overtime/Commission Bonus (list whether cash, stock, option, etc) Draw Pension and retirement benefits Interest income Dividend income Trust income Social Security Payments Unemployment benefits Disability payments Worker’s Compensation Public Aid/Food Stamps Financial Disclosure Statement Pursuant to Local Court Rule Page 9 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ Investment income Rental Income Business income, Partnership, Sub-Chapter S, or LLC income (specify) Royalty income, Fellowships, Stipends, Annuity (specify) $0.00 TOTAL MONTHLY GROSS INCOME FROM ALL SOURCES Required Monthly Deductions Federal Tax (based on _____ exemptions) State Tax (based on _____ exemptions) FICA (or Social Security equivalent or Self Employment Tax) Medicare Mandatory retirement contributions required by law or as condition of employment) Union Dues (Name of Union: ______________________________) Health/Hospitalization Premiums (Is this a Pre Tax Plan? Yes [ ] or No [ ] ) Prior obligation(s) of support actually paid pursuant to Court order $0.00 Total Required Deductions Voluntary Deductions from Income 401(k) Flexible Spending Health Savings Account Plan Other (Specify) Total Voluntary Deductions $0.00 CURRENT MONTHLY LIVING EXPENSE OF _______________ HOUSEHOLD EXPENSES a. Mortgage or rent - Circle the one that applies b. Home equity loan/Second mortgage Financial Disclosure Statement Pursuant to Local Court Rule Page 10 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ c. Real estate taxes, assessments d. Home owners or renters insurance e. Natural Gas/Heat f. Electricity g. Telephone, long distance, cell phone(s), modem lines h. Cable and Internet Access, Satellite i. Water and sewer & 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, liquor, household supplies, etc.) p. Date: _________________________ Other (specify) SUBTOTAL HOUSEHOLD EXPENSES $0.00 TRANSPORTATION EXPENSES a. Gasoline b. Repairs. Maintenance c. Insurance/license/city stickers d. Payments/replacement e. Alternative transportation f. Parking/tolls g. Other (specify) SUBTOTAL TRANSPORTATION EXPENSES $0.00 PERSONAL EXPENSES (excluding children’s expenses) Financial Disclosure Statement Pursuant to Local Court Rule Page 11 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ a. Clothing b. Grooming c. Medical (after insurance proceeds/reimbursements): (1) (2) Dentist (3) Optical (4) Medication (5) d. Doctor Counseling Insurance (1) (2) Medical/Hospitalization Insurance Premiums (if not deducted from paycheck) (3) e. Life Insurance Premiums (specify term/whole) Dental/Optical Insurance Premiums (if not deducted from paycheck) Other (specify) $0.00 SUBTOTAL PERSONAL EXPENSES MISCELLANEOUS EXPENSES a. Clubs/social obligations/entertainment/dining out b. Newspapers, magazine, books c. Gifts d. Donations, church or religious affiliation e. Vacations (not including children) f. Computer/supplies/software g. Other (specify) SUBTOTAL PERSONAL EXPENSES - Miscellaneous Expenses $0.00 CHILD(REN)’S SEPARATE EXPENSES a. Clothing Financial Disclosure Statement Pursuant to Local Court Rule Page 12 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ b. Grooming c. Date: _________________________ Education (1) (2) Books/fees (3) Lunches (4) Transportation (5) d. Tuition School sponsored activities Medical (after insurance proceeds) (1) Doctor (2) Dentist (3) Optical (4) Medication (5) Counseling e. Allowance f. Childcare/Pre-School/Before and after school care/Sitters g. Lessons/extracurricular activities/supplies h. Clubs/summer camp i. Vacation (children only) j. Entertainment k. Gifts to others l. Other (specify) SUBTOTAL CHILD(REN)’S EXPENSES $0.00 BUSINESS EXPENSES (not reimbursed by employer) Membership/Trade Association/Other dues or fees: Association Name(s): Financial Disclosure Statement Pursuant to Local Court Rule Page 13 of 14 American LegalNet, Inc. www.FormsWorkFlow.com Case # _____________________ Date: _________________________ Malpractice/Professional Liability Insurance Premiums Accountants/Other Professional Services Utilized Political Contributions Office upkeep expenses (cleaning services, etc.) Postage Travel Clinic/Business Entertainment Other (specify) SUBTOTAL BUSINESS EXPENSES $0.00 TOTAL MONTHLY LIVING EXPENSES $0.00 RECAP NET MONTHLY INCOME $0.00 TOTAL MONTHLY LIVING EXPENSES $0.00 DIFFERENCE BETWEEN NET INCOME AND EXPENSES $0.00 LESS MONTHLY DEBT SERVICE $0.00 INCOME AVAILABLE PER MONTH $0.00 CERTIFICATION OF DOCUMENT PRODUCTION I, ______________________________, certify that the attached corroborating documents 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. __________________________________________ Signature Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this statement are true and correct, except as to matters therein stated to be on information and belief and ad to such matters the undersigned certifies as that he/she verily believes the same to be true. __________________________________________ Signature of Affiant Financial Disclosure Statement Pursuant to Local Court Rule Page 14 of 14 American LegalNet, Inc. www.FormsWorkFlow.com