_______________________________ Name _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Phone Number WIFE, PETITIONER PRO SE _______________________________ Name _____________________________________ Address _____________________________________ City State Zip Code _____________________________________ Phone Number HUSBAND, PETITIONER PRO SE MONTANA _______________ JUDICIAL DISTRICT COURT _____________________ COUNTY In re the Marriage of: Cause No.: _________________ ________________________, Petitioner, and [ ] Wife’s/[ ] Husband’s Final Declaration of Disclosure of Assets, Debts, Income, and Expenses ________________________, Petitioner. Warning: Montana law requires the full disclosure of all assets, debts, income, and expenses. Failure of either party to file a complete financial disclosure statement shall authorize the Court to accept the statement of the other party as accurate. Any deliberately false statement made hereon or on any schedules or attachments may subject you to the penalty of perjury or other appropriate relief and may be considered a fraud upon the Court. If you need additional space on which to list your assets, debts, income, or expenses, please attach additional sheets of paper as necessary. Do not write in the margins or on the reverse sides of the pages of this document. Declaration of Disclosure, Page 1 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com 1. Disclosure of Assets a. Real Estate Estimated. Value Description Name(s) on Title Estimated Value Name(s) on Title Address: ___________________________________ Legal Description:____________________________ ___________________________________________ Is there a secured debt on the property? [ ] Yes [ ] No If yes, amount owed: __________ As of: / / Lender: ____________________________________ Address: ___________________________________ Legal Description:____________________________ ___________________________________________ Is there a secured debt on the property? [ ] Yes [ ] No If yes, amount owed: __________ As of: / / Lender: ____________________________________ b. Vehicle(s) Description Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ Declaration of Disclosure, Page 2 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com Estimated Value Description As of: / / Name(s) on Title Balance as of / / Name(s) on Account Lender: _____________________ Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ Year/Make/Model: ___________________________ VIN#: _____________________________________ Is there an outstanding loan on the vehicle? [ ] Yes [ ] No If yes, amount owed: _____________ As of: / / Lender: _____________________ c. Bank Accounts and Cash Description (include name of bank and account number) Cash XXXXXXXX Declaration of Disclosure, Page 3 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com d. Description e. Description Pensions/Retirement Accounts; Life Insurance (Cash Value); Stocks, Bonds, Secured Notes, Mutual Funds Estimated Value Name(s) on Account Personal Property (including appliances, furniture, jewelry, art, guns, etc.) Estimated Value Declaration of Disclosure, Page 4 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com Estimated Value Description f. Business Interests (including equipment, tools, livestock, etc.) Description g. Estimated Value Estimated Value Name(s) on Title Other Assets Description 2. Name(s) on Title Disclosure of Debts Description Creditor Amount Owed Name on Debt Secured Debt on Real Property (See 1(a) above) XXXXX XXXXXXXXX Declaration of Disclosure, Page 5 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com Description Creditor Vehicle Loan(s) (See 1(b) above) Amount Owed XXXXX Name on Debt XXXXXXXXX Utility Bill(s): Credit Card(s): Student Loan(s): Medical Expenses: Other Liabilities: 3. Disclosure of Income The [ ]Wife/ [ ]Husband has the following income: Source of Income Amount per Month Gross Wages, Salary, Commissions Rents, Interests, Dividends Declaration of Disclosure, Page 6 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com Source of Income Amount per Month Self Employment Earnings Unemployment or Worker’s Compensation Social Security Benefits, including SSI Public Assistance Food Stamps Pension, Retirement Child Support Dependent’s Benefits Other Income (describe): 4. Disclosure of Expenses The [ ] Wife/[ ] Husband has the following expenses: Description of Expense Amount per Month Taxes and other money withheld from income Retirement Health Insurance (self and children) Medical Expenses Housing (rent or mortgage payment) Property Taxes Property Insurance Transportation Car Insurance Student Loans Declaration of Disclosure, Page 7 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com Amount per Month Description of Expense Utilities Telephone Clothing Food and Household Supplies Child Care Child Support Payments Other Expenses (describe): DATED this ____ day of _______________________, 20___. Signature Print Name [ ] Wife/ [ ] Husband, Petitioner Pro Se STATE OF MONTANA COUNTY OF ) ) ss. ) SUBSCRIBED AND SWORN TO before me this _____ day of ____________________, 20____. (Seal) Name (printed): ______________________ Notary Public for the State of Montana Residing at My commission expires Declaration of Disclosure, Page 8 of 8 Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02 American LegalNet, Inc. www.FormsWorkflow.com