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Preliminary Verified Disclosure Statement Form. This is a Kentucky form and can be use in Fayette Circuit Court Local.
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Tags: Preliminary Verified Disclosure Statement, FC-2, Kentucky Local, Fayette Circuit Court
COMMONWEALTH OF KENTUCKY
FAYETTE FAMILY COURT
DIVISION
IN RE THE MARRIAGE OF:
PETITIONER
NO.
PRELIMINARY VERIFIED
DISCLOSURE STATEMENT
VS.
-CIRESPONDENT
Petitioner 0 Respondent submits under oath the following Preliminary Verified
Disclosure Statement pursuant to RFFC 14 which requires full and prompt disclosure of the
following information:
NOTE : A RESPONSE OF "SEE ATTACHED" IS NOT APPROPRIATE FOR ANY PORTION
OF THIS STATEMENT . ATTACH DOCUMENTS REQUESTED HEREIN ONLY.
A.
BACKGROUND INFORMATION :
Maiden Name :
1 . Name :
2. Current Address:
3. Date of Birth:
4. Number of Prior Marriages:
5. Minor Children From Prior Marriages:
Name
6. Date of Marriage :
7. Date of Separation :
8. Children of This Marriage :
Name
I
State of Birth:
How Each Terminated:
Date of Birth
I
Residing With
Where License Obtained :
I
Date of Birth
FC-2 Preliminary Verified Disclosure Statement
I
Residing With
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When :
9.
Have You Attended the Parents Education Clinic?
Have Children in Grades 1-5 Attended Kids Time?- When :
10.
11 .
Is There an Emergency Protective Order or a Domestic Violence Order in Effect
If so, ATTACH COPY OF ORDER (all pages).
Regarding These Parties?
Filed by Either Party for an Emergency Protective Order?
12.
Is There a Petition Pending
If so, ATTACH COPY OF PETITION (all pages) .
B. EMPLOYMENT INFORMATION:
1 . Current Employer :
Address :
Length of Employment:
Present Position :
How Often Paid :
Gross Pay Per Pay Period (including overtime):
Net Pay Per Pay Period (including overtime):
2 . Other/Additional Employer:
Address:
Length of Employment:
Present Position :
How Often Paid :
Gross Pay Per Pay Period (including overtime):
Net Pay Per Pay Period (including overtime): 3. Self-Employment:
Name of Business :
Type of Business : .
Address:
Length of Self-Employment:
Present Position :
Gross Income Year to Date:
Ordinary and Necessary Business Expenses Year to Date (list and give totals):
Gross Income Last Year from Self-Employment:
Net Income Last Year from Self-Employment:
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ATTACH COPIES OF LAST THREE PAY STUBS FROM EACH EMPLOYER, LAST YEAR'S
W-2(S) AND LAST THREE STATE AND FEDERAL TAX RETURNS.
C.
ADDITIONAL INCOME RECEIVED IN LAST 12 MONTHS (Specify amounts) :
1.
Employment Benefits :
Commissions:
Bonuses, incentives, etc.:
Health Insurance paid by employer
Housing expenses :
Automobile expenses :
Payment/lease:
Mileage:
Repairs:
Gas:
Amount
Insurance:
Phone/Mobile phone expenses :
Meals or allowance:
Club dues :
Others (list all and specify amount or value) :
2.
Interest and Dividends :
Source
3.
Unemployment :
4.
Worker's Compensation:
5.
Social Security/SSI :
6.
AFDC:
7.
Child Support:
8.
Maintenance:
9.
Retirement Benefits :
10. Others (list all and give amounts) :
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D. CHILD SUPPORT GUIDELINE INFORMATION:
1 . Medical Insurance:
Who pays:
How paid :
How Much for Child(ren) Only:
2. Dental Insurance:
Who pays :
How paid :
How Much for Child(ren) Only:
3. Child Care Costs:
Who Provides :
How Often is Provider Paid :
Name of Provider:
How Much Paid :
4.
5.
6.
7.
8.
Amt. Paid for Court Ordered Child Support for Prior Born Child(ren) :
Amt. Paid for Court Ordered Maintenance for Prior Marriage(s):
Imputed Child Support for Prior Born Child(ren) :
Child Support Received for Child not of this Marriage :
Maintenance Received from Prior Marriage :
E. NONMARITAL PROPERTY CLAIMS :
List all property, real or personal, tangible or intangible, of greater than $100.00 in value, which
you claim to be either entirely or partially your nonmarital property .
Item 1--Specify item :
Fair Market Value at Date of Marriage :
Debt Balance on Item at Date of Marriage :
Current Debt Balance on Item :
Current Fair Market Value:
Basis for your Claim Item is Nonmarital :
Nonmarital Value of Item :
Item 2--Specify item
Fair Market Value at Date of Marriage :
Debt Balance on Item at Date of Marriage :
Current Debt Balance on Item :
Current Fair Market Value:
Basis for your Claim Item is Nonmarital :
Nonmarital Value of Item :
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F. MARITAL PROPERTY :
1 . Real Property:
Address
I
mortgage(s)
Balance
Fair Market Value
2. Vehicles, Motorcycles, Boats, Trailers, Equipment, etc. :
YeaWake/ModellType
3. Bank Accounts *
(
- -
I
4. Investments (Stocks, Bonds, Mutual Funds, Stock Options, etc.)*:
I
Type and Location of Investment
5. Life Insurance*:
Co. and Type of Policy
Loan Balance
Fair Market Value
Bank and Type of Account
Insured
Interest
Balance
# ofshares
I
Fair Market Value
Cash
Surrender
Value
Loan
Balance
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements from
retirement plans, periodic statements reflecting assets held in name of or on behalf of children,
and documents reflecting debts and credit card statements for past 12 months should be in
possession of answering party or answering party's attorney when this statement is served on
the opposing party.
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6. Assets Held in Name of/on Behalf of Children*
Type -& Name of Account
I
7. Retirement Plans (Pensions, 401(k), Tax Deferred Savings, IRAs, etc.)*:
Plan Administrator
Type and Name of Plan
8 . Interests In/Ownership of Business :
Location of Business, Business
Name & Address
and Type of Business
9. Household Property in Dispute:
I Location
Item
Balance or Value
Balance or Value
Tax Returns & Financial
Documents
Fair Market
Value
Loan
Balance
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements from
retirement plans, periodic statements reflecting assets held in name of or on behalf of children,
and documents reflecting debts and credit card statements for past 12 months should be in
possession of answering party or answering party's attorney when this statement is served on
the opposing party.
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10. Safety Deposit Box?
Location
No
Yes
I
Contents
If yes:
Value
Date of Last
Visit
11 . Other Property - (specify item and value) :
Jewelry:
Furs :
Antiques :
Art:
Collections:
Country Club Memberships:
Season Tickets:
Income Tax Refunds Expected :
Frequent Flyer Miles:
Accounts Receivables/Loans :
Claims Against Others:
Accrued Vacation Pay:
Others:
G. DEBTS*:
Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets,
periodic statements from investments, statements on life insurance, periodic statements
from retirement plans, periodic statements reflecting assets held in name of or on behalf of
children, and documents reflecting debts and credit card statements for past 12 months
should be in possession of answering party or answering party's attorney when this
statement is served on the opposing party.
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H. MONTHLY EXPENSES (Specify amounts) :
_
Rent:
Mortgage :
~~
Property Tax :
__
Homeowner's/Renter's Insurance:
House Maintenan ce:
_
Electric Utilities :
_
Fuel, Oil, Gas Utilities :
Telephone :
Cellular Phone :
_
Water and Sewer.
Garbage Pickup:
_
Yard Expense:
Cleaning Service:
_
Child Care/Babysitter:
Cable Television:
Car Pa ments/Lease Payments :
Auto Gas and Oil:
Car Maintenance and Repairs:
Car Licenses/Taxes
Car Insurance :
Religious/Charitable Contribution s:
Clothing:
Uniforms:
Dry Cleaners:
Entertainment :
Gifts:
Food:
Doctor :
Dentist :
Orthodontist:
Prescrio-:,ij~~zmVm ;~s/Medicines:
Optometrist/Ophthalmologist/Eyeg lasses: w
Medical/Dental Insurance (not deducted from pay) :
_Life Insurance (not deducted from pay) :
_
Disability Insurance (not deductedfrom pay):
Newsp!eTer:
MaV12r~~~~aptions:
-.
Veterinarian/Pet Food:
Professional Dues/Club Memberships :
Social Clubs:
Barber/Beauty Shoes
Tuition/School Expenses:
State/Fe deral/Local Taxes Not Withheld :
__
^_
Child support paid forprior born child
Child support for child of marriage
_Maintenance ~~i66- pua"
ouse
Maintenance _paid to current spouse
Athletic and Activity Fees (list)
FC-2 Preliminary Verified Disclosure Statement
Actual
Antici " aced
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Actual
Debt payments (list)
Anticipated
Other Monthly Expenses list
TOTAL MONTHLY EXPENSES
O Petitioner 0 Respondent states that the above information is true and correct to the best of
my knowledge and belief, and that it results from a diligent, good faith effort to ascertain the
information sought herein, based upon information and documents available to me and/or within
my possession or control . All documents upon which this information is based and the
documents requested herein have been produced and are currently in the office of my counsel .
0 Petitioner 0 Respondent
STATE OF KENTUCKY
)
COUNTY OF
)
day of
SCT.
on this the,
Subscribed and sworn to before me by
My commission expires:
Notary Public,
CERTIFICATE OF SERVICE
This is to certify that the foregoing Preliminary Verified Disclosure Statement was 0
day of
mailed 0 hand-delivered to counsel for 0 Petitioner 0 Respondent on this the
and supporting the information set
and documents requested
forth herein are currently available at the undersigned's office or are in the undersigned's
possession and are available for inspection and copying at the requesting party's expense.
ATTORNEY FOR 0 PETITIONER 0 RESPONDENT
or 0 PETITIONER 0 RESPONDENT
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