IN THE CIRUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS IN RE THE MARRIAGE OF: No.: Petitioner and Respondent FINANCIAL STATEMENT GROSS INCOME 1 2 3 GROSS WAGES OR SALARY ADDITIONAL INCOME (State Source) (add lines 1 and 2) TOTAL GROSS INCOME PER MONTH DEDUCTIONS 4 FICA (Social Security Tax) 5 Federal Tax Withholding 6 State Tax Withholding 7 Union Dues 8 Mandatory Retirement Deductions 9 Health & Hospital Insurance Premiums 10 Installment debt payments for medical bills 11 Court-ordered Child Support & Maintenance Case # County & St. 12 Necessary Expenses for Production of Income 13 (add lines 4 thru 12) TOTAL DEDUCTIONS 14 (subtract line 13 from line 3) NET INCOME PER MONTH 15 PAY PERIOD 16 TAX FILING STATUS PRINT NAME Exemptions Claimed ADDRESS CITY, STATE, ZIP REVISED MARCH 2009 American LegalNet, Inc. www.FormsWorkFlow.com HOUSING EXPENSES 17 18 19 20 21 22 23 Rent or Mortgage Payments Homeowner's or Rental Insurance Real Estate Taxes Repairs and Maintenance of Home TOTAL HOUSING (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 22 from like 21 and enter here) YOUR SHARE UTILITIES 24 25 26 27 28 29 30 31 32 33 Gas Water Electricity Telephone Cable TV and Satelite Fees Trash Service Sewer TOTAL UTILITIES (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 32 from like 31 and enter here) YOUR SHARE TRANSPORTATION 34 35 36 37 38 39 40 41 42 43 44 45 46 47 Gasoline Maintenance and Repairs Registration (plates) Auto Insurance Payment on Auto Loan TOTAL TRANSPORTATION (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 40 from like 39 and enter here) YOUR SHARE INSURANCE (NOT Auto or Health) Life Insurance Premimums (total of line 71; monthly average) Dental Insurance Premiums Other Insurance Premiums (described) TOTAL INSURANCE (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 46 from like 45 and enter here) YOUR SHARE American LegalNet, Inc. www.FormsWorkFlow.com YOURS 48 49 50 51 52 53 54 55 56 57 58 59 CHILDREN Food Clothing Medical and Dental Care, Glasses and Drugs Recreation Laundry and Cleaning Hair Care School Expenses and School Lunches Day Care Center or Baby Sitter Charitable and Religious Contributions Other Expenses (attach sheet and enter total here) (Add lines 23, 33,41, 47 and 48 thru 57) YOUR TOTAL EXPENSES (Add lines 22, 32, 40, 46 and 49 thru 57) CHILDREN'S TOTAL EXPENSES 60 REAL ESTATE MORTGAGE HOLDER RELATED DEBT MARKET VALUE 61 MOTOR VEHICLES LOAN HOLDER RELATED DEBT MARKET VALUE EQUITY LOAN HOLDER RELATED DEBT MARKET VALUE EQUITY 62 HOUSEHOLD AND PERSONAL GOODS OVER $300 EACH EQUITY TOTAL OF GOODS LESS THAN $300 EACH American LegalNet, Inc. www.FormsWorkFlow.com 63 RETIREMENT, PENSION, PROFIT SHARING PLANS AND IRA'S Number of Number of NAME OF COMPANY Begin & End Months Married Months of Current Dates During Accural Accrual Value 64 NAME OF COMPANY STOCKS, BONDS, MUTUAL FUNDS PURCHASE NAME(S) OF NUMBER OF SHARES DATE OWNER(S) 65 BANK AND SAVINGS AND LOAN ACCOUNTS BANK & ACCT. NO. NAMES CD VALUE SAVINGS CURRENT VALUE CHECKING 66 CASH IN YOUR POSSESSION OR CONTROL Î 67 LAWSUITS AND WORKMAN'S COMPENSATION CLAIMS-- PENDING OR TO BE FILED NAME OF DEFENDANT 68 NAME OF DEBTOR CASE NUMBER COUNTY STATE TYPE OF ACTION MONEY OWED TO YOU RELATIONSHIP DATE LOAN DUE TO YOU MADE DATE AMOUNT CLAIMED CURRENT AMOUNT American LegalNet, Inc. www.FormsWorkFlow.com 69 DEBTS OWED TO FRIENDS OR RELATIVES NAME OF RELATIONSHIP PURPOSE DUE CURRENT FRIEND OR RELATIVE TO YOU OF DEBT DATE BALANCE 70 DEBTS OTHER THAN DEBT RELATED TO ABOVE PROPERTY NAME OF DATE OF CREDITOR LOAN 71 NAME OF COMPANY PURPOSE DUE AMOUNT DATE LIFE INSURANCE OWNER INSURED POLICY NUMBER AMOUNT MISCELLANEOUS INFORMATION I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, THAT THE FOREGONG INFORMATION IN THIS FINANCIAL STATEMENT IS TRUE AND CORRECT. YOUR SIGNATURE Subscribed and sworn to before me, the undersigned Notary Public, on this________ day of _______________, 20_______. My Commission expires___________. Notary Public American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR FINANCIAL STATEMENT MONTHLY AVERAGES- USE MONTHLY AVERAGES FOR ALL FIGURES. There are 4.33 weeks in an average month. For example, if you have a weekly amount for your income, multiply it by 4.33 t0 convert it to monthly. If you have a figure for two weeks, multiply it by 26 and divide by 12. TRY TO PREDICT THE FUTURE- Based on your current expenses and your future needs do your best to estimate your expenses for the period after the divorce. CHILDREN'S EXPENSES- Fill in items relating to children only if you will have, or expect to have, minor children living with you and only if you have a legal obligation to support them. Do not include expense figured for stepchildren or children from a prior marriage. There are two exceptions. Do include children over 18 if there is a request for educationsl expenses, attach written information from the school relating to the expenses claimed. Also attach written responses to applications for scholarships and grants. The other exception relates to insurance premimums. See instrucions for items 42, 43,44. ATTACHMENTS RELATING TO INCOME- You must attach the following to your Financial Statement: all pages and W-2 forms of your last-filed Federal Income Tax Return; a current pay stub showing your yearto-date earnings and deductions. FAIR MARKET VALUE (FMV)- Fair market value is defined as an amount that a buyer would pay for the item in it's current condition in a normal market such as newspaper want ads, a used car lot, comparable real estate sales, or auction. FMV if a used item is not what you paid for it when it was new, although that price can be used as guidance. NO DUPLICATION OF EXPENSES-Do not duplicate expenses. For example, do not list dental insurance on item 9 and then list it again on item 43. NON-MARITAL PROPERTY- This Financial Statement does not contain any space for lising non-marital property. Ask your attorney about this. Attach a separate page listing marital property and indicate when and how it was acquired and the fair market values. INSTRUCTIONS FOR SPECIFIC LINES 2 Include rental income, dividends, interest, business enterprises, social security, AFDC, VA benefits, pensions, annuities, bonuses, commissions, tips and all other sources of income. 5 List the amount of Federal Income Tax withheld or your average estimated tax payments. It should be based on your Tax Filing Status and the number of exemptions you list in line 16. 6 State Income Tax Withholding properly calculated. 7 Union Dues. Monthly average. 8 List Mandatory Retirement Deductions required by law or as a condition of employment. OVER American LegalNet, Inc. www.FormsWorkFlow.com List amount of Dependent and Individual Health/Hospital premiums withheld or paid directly for you and 9 children in your custody. Do not unclude dental insurance unless it is a mandatory part of a health care package. Do not list life, auto, home or rental insurance. 10 List monthly average of payments on debts reltaing to medical treatment necessary for the preservation 11 of life or health. Cosmetic surgery should not be included. Attach itemized bills. List amounts actually paid pursuant to a Court order and include the case number and the County and State where entered. Attach a copy of the order. Do not include amounts in temporary orders. 12 List the average monthly amount of expenses necessary for the production of income. Attach an itemized list and be prepared to justify each item. 15 Indicate whether you are paid weekly, bi-weekly, twice per month or monthly. 16 TAX FILING STATUS. State your filing status (e.g. married or single) and list the total number of Federal Income Tax exemptions that you or your employer used to calculate the federal taxes withheld and that you listed in item 5. 18 Do not list real estate taxes or homeowners insurance premiums if already listed as part of your 19 mortgage payments in line 17. 36 Auto registration expense should be divided by 12 and entered. 37 List total amount of insurance for all vehicles you expect to be awarded. 42 List the amount of premiums paid for you and your children if this marriage even if you do not have 43 custody. Do include premiums for your children who were not born to this marriage. Do not include 44 step-children. Do not include step-children. Do not duplicate premiums liste don lines 9, 18 or 37. Be prepared to itemize the premiums. 46 List actual portion of premium paif for insurance on the life of your children. Do not duplicate this expense elsewhere. 61 Motor Vehicles includes autos, truck, motorcycles, aircraft, boats and mobile homes List items with a current market value of over $300 each. If there are more then eight items, obtain 62 a Personal Property Sheet from your attorney. For the last line, total all of the propertyitems that do not have a value of more than $300. There is no need to describe the individual items with a value of less than $300. 63 BEGIN & END DATES means the dates you started/ended your employment with the sompany or joined the union with which you have a pension or profit sharing plan. 65 Include the account number below the dashed line under the name of the bank. Attach copies of CD's and copies of your most recent savings and checking account statements. 69 Attached copies of notes or any type of document that you have in your possession showing that you owe the amounts listed here. 70 List credit card balances and, bank loans and any other type of dept which is not secured by any property. Attach copies of your most recent credit card statements and loan papers. REVISED MARCH 2009 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL PROPERTY SHEET ITEM PROPERTY DESCRIPTION PETITIONER FMV M/O H/W IMPORTANT: EACH PROPERTY ITEM MUST BE NUMBERED: REPONDENT FMV M/O H/W COURT'S RULINGS FMV M/O H/W H - AWARD TO HUSBAND W - AWARD TO WIFE COURT'S NOTES M - MARITAL O - NON- MARITAL American LegalNet, Inc. www.FormsWorkFlow.com