CODE: Nevada Bar No. Attorney For IN THE FAMILY DIVISION JUDICIAL DISTRICT COURT OF THE , STATE OF NEVADA IN AND FOR THE COUNTY OF Plaintiff or Petitioner Case No. Dept. No. Defendant or Respondent / FINANCIAL DISCLOSURE FORM Financial Statement of: First name Middle Last name Occupation: Employed by: From: Previously Employed by: To: `From: To: Age & Date of Birth: Level of Education: Level of Disability, if Any: Marriage Date, If Applicable: Present Home Address: How many adults (over 18) live with you? How much do you receive from each of them each month? I have paid my attorney a retainer of $ ; and his/her hourly rate is $ I am the _____Plaintiff/Petitioner _____ Defendant/Respondent in the above action. I swear under penalty of perjury, that the contents of this Financial Disclosure Declaration are true to the best of my knowledge as of this date. I understand that by my signature I verify the material accuracy of the contents. I also understand that any willful misstatements may be contemptuous and could result in my punishment by the Court. I understand I have a duty to supplement this form upon discovering additional assets or debts or upon changed circumstances within 10 days of discovery. I declare under penalty of perjury that the foregoing and following are true and correct. Executed on ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Signature Nevada Supreme Court Revised: October 18, 2007 Page 1 of 7 Case No. Dept. No. PERSONAL INCOME SCHEDULE IF SELF-EMPLOYED OR BUSINESS OWNER PLEASE FILL IN THE BUSINESS INCOME/EXPENSE SCHEDULE YOUR OWN INCOME EMPLOYMENT INCOME (if paid weekly multiply by 52 and divide by 12, if paid every two weeks, multiply by 26 and divide by 12) 1 AMOUNT NOTE: ATTACH COPIES OF YOUR THREE MOST RECENT PAY STUBS Average Gross Monthly Income from Employment (all employment income including salary $________ + bonuses $________ + overtime $________ + commissions $________ + tips $________ + other $________ = Average Monthly Paycheck Deduction – Income Taxes 2 Average Monthly Paycheck Deduction – Social Security 3 Average Monthly Paycheck Deduction – Medicare 4 Average Monthly Paycheck Deduction – Health Insurance 5 Average Monthly Paycheck Deduction – Retirement Plan or 401(k) 6 Average Monthly Paycheck Deduction – Savings Account 7 Average Monthly Paycheck Deduction(s) – Other 8 9 Total Paycheck Deductions Per Month (Add lines 2-8 above) 10 Average Net Monthly Income from Employment (Subtract line 9 from line 1) OTHER INCOME Monthly Spousal Support/Alimony Awarded by a Court 11 12 Monthly Child Support: court ordered $_______ + other/voluntary child support $_______ = Investment Income (Dividends, interest and capital gains) 13 14 Rental Income (Enter the Amount of Depreciation Claimed in Computing Rental Income Here: $_______) 15 Retirement Income Including Defined-Benefit Distributions, 401(k) Distributions, military retirement Social Security Retirement 16 Social Security Disability/military disability 17 Supplemental Security Income (SSI) 18 Unemployment Benefits 19 Workers Compensation Payments 20 21 Other Sources of Income (Describe: such as direct contributions from roommates or indirect payment of expenses by roommates) Total Other Income Per Month (Add lines 11-21) 22 23 TOTAL INCOME PER MONTH (Add lines 10 and 22) ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 2 of 7 Case No. Dept. No. 1 PERSONAL EXPENSE SCHEDULE (NOTE: ALL EXPENSES LISTED BELOW SHOULD BE ON AN AVERAGE MONTHLY BASIS annual payments divided by 12, semiannual payments divided by 6, and quarterly payments divided by 3) Mortgage or Rent: 1st Mtg. $________ + 2nd Mtg. $________ + line of credit $________ + taxes $_________ + insurance __________ = 2 Utilities: Gas/Oil $________ + electricity $________ + TV/cable $________ + water &________ + garbage ________ = 3 Telephone: landline $________ + cellular $________ + Internet $________ + fax $________ + other $________ = 4 Food, Groceries & Incidentals (not including entertainment or dining out) 5 Transportation: monthly payment/lease $________ + gas and oil ________ + repairs and maintenance, tires $________ + insurance $________ + license/registration $________+ parking $________ + public transportation $________ + other $________ 6 House Maintenance: housekeeping $________ + garden/lawn care $________ + snow removal $________ + repairs & maintenance $________ + other $________ 7 Entertainment: dining out $________ + movies, shows $________ + music/videos $________ + other $________ = 8 Dues, Memberships, Fees: Professional $________ + memberships (health club, country club) $_________ homeowners $_________ fraternal $________ + business $________ + other $________ = 9 Health/exercise: clothing/shoes $________ + fees/passes (health clubs etc.) $________ + other $________ = 10 Clothing: self $________ + children $________ + cleaning $________ = 11 Vacations 12 Pets: Food $________ + boarding $________ + healthcare $________ + grooming $________ + other $________ = 13 Healthcare: Insurance $________ + unreimbursed; medical $________ + dental $________ + orthodontic $________ + medications $________ + counseling $________ + physical therapy $________ + chiropractic $________ + other $________ = 14 Appearance: hair $________ + nails $________ + facials/massage $________ + cosmetics $________ + other $________ = 15 Insurance: life $________ + disability $________ + other $________ = 16 Books, Newspapers & Magazines 17 Church/Charitable 18 Accounting & Tax Preparation 19 Support of Others: Ordered Child Support $________ + voluntary child support $________ + court-ordered spousal support $________ + eldercare $________ = 20 Miscellaneous: Gifts $________ + storage $________ + flowers $________ + savings $________ + Lawyers fees $________ + other $________ = 21 Education: Tuition, Books & Fees $________ + extracurricular $________ + sports $________ + music $________ + other $________ = 22 Childcare: day care $________ + preschool $________ + other $________ = 23 Minimum Charge Card Payments and other consumer/installment debt: credit card #1 $________ + credit card #2 $________ + credit card #3 $________ + credit card #4 $________ + other debt $________ = 24 TOTAL AMOUNT TOTAL MONTHLY EXPENSES (Add lines 1-23 above) ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 3 of 7 Case No. Dept. No. INCOME/EXPENSE SUMMARY SCHEDULE Total Monthly Income from Personal Income Schedule Line 23 Add: Total Average Net Monthly Income from Self-Employment or Business Schedule Line 30 Less: Total Monthly Expenses from Personal Expense Schedule line 24 Net Monthly Income or (Loss) ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 4 of 7 Case No. Dept. No. ASSET AND DEBT SCHEDULE NOTE: PLEASE USE ADDITIONAL ASSET AND DEBT SCHEDULES, AND CARRY TOTALS TO THIS SCHEDULE IF YOU NEED TO LIST ADDITIONAL ASSETS AND DEBTS BEYOND THE LINES PROVIDED ON THIS SCHEDULE. PROPERTY VALUE (List all assets and debts @ current values) Note: In general, Separate Property is defined as that acquired before marriage, or after marriage by gift or inheritance. COMMUNITY TOTAL SEPARATE HUSBAND WIFE ASSETS CASH: include the last four numbers of the account, and the name and location including the branch of the institution, including CDs. 1 2 3 4 Subtotal INVESTMENTS: Include mutual funds, stocks, bonds, brokerage accounts, and other investment accounts. Provide the last four numbers of the account, and the name and location including the branch of the institution. 5 6 7 8 Subtotal BUSINESS INTERESTS: If you own all or part include. Indicate percentage of ownership here. 9 10 11 Subtotal RECEIVABLES & DEPOSITS 12 13 Subtotal REAL PROPERTY. Provide common address and type of property, e.g., condominium, townhouse, single-family residence, commercial or retail. 14 15 16 17 18 Subtotal AUTOS & RECREATIONAL VEHICLES. Provide make, model, mileage, and vehicle identification number. 19 20 21 22 23 24 Subtotal PERSONAL PROPERTY. Provide information on furniture, electronics, household goods, tools, computers, artwork, precious metals and jewelry having value of $500 or greater. 25 26 27 28 29 30 31 32 32 34 35 Subtotal ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 5 of 7 Case No. Dept. No. ASSET AND DEBT SCHEDULE NOTE: PLEASE USE ADDITIONAL ASSET AND DEBT SCHEDULES, AND CARRY TOTALS TO THIS SCHEDULE IF YOU NEED TO LIST ADDITIONAL ASSETS AND DEBTS BEYOND THE LINES PROVIDED ON THIS SCHEDULE. PROPERTY VALUE (List all assets and debts @ current values) Note: In general, Separate Property is defined as that acquired before marriage, or after marriage by gift or inheritance. COMMUNITY TOTAL SEPARATE HUSBAND WIFE CASH VALUE OF LIFE INSURANCE. Provide information on any loans against the cash rounder value of a life insurance policy. 36 37 38 Subtotal RETIREMENT ACCOUNTS. Provide the name of the account, account number, an administrator. Provide any information on loans against retirement assets. 39 40 41 42 43 Subtotal 44 TOTAL ASSETS (add Lines 4,8,11,13,18,24,35,38 and 43) DEBT LONG TERM DEBT. Provide information on mortgages, notes & deeds of trust, home equity loans and lines of credit, and automobile, recreational vehicle loans and leases. 45 46 47 48 49 50 Subtotal OTHER DEBT. Charge accounts, credit cards, medical debts, and other shortterm debts. Provide the name of the lender, and the last four numbers of the account. 51 52 53 54 55 56 57 58 59 Subtotal 60 TOTAL DEBT (add lines 50 and 59) 61 NET WORTH (TOTAL ASSETS, line 44 MINUS TOTAL DEBT, line 60) ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 6 of 7 Case No. Dept. No. BUSINESS INCOME/EXPENSE SCHEDULE (Skip this schedule if you are not self-employed or do not own a business) 1 2 Cost of Sales or Cost of Goods Sold (if applicable) 3 Gross Profit (Subtract Line 2 from Line 1) 4 Advertising 5 Car and truck 6 Commissions and fees 7 Deductible meals 8 Depletion 9 Depreciation and section 179 10 Employee benefit programs 11 Entertainment 12 Insurance (other than health) 13 Interest 14 Legal and professional 15 Mortgage on building or office space (paid to banks, etc.) 16 Office expense 17 Other 18 Pension and profit-sharing plans 19 Rent 20 Repairs and maintenance 21 Supplies 22 Taxes and licenses 23 Travel 24 Meals 25 Utilities 26 Wages 27 Total Business Expenses Per Month Including Cost of Sales (Add Lines 4-26) 28 Average Gross Monthly Income from Self-Employment or Business (Subtract Line 27 from Line 3) 29 Average Estimated Tax Payments on a Monthly Basis (Estimated Tax Payments are made on a quarterly basis. As a result, the required quarterly payment would be divided by three to calculate the average monthly estimated tax payment.) 30 AMOUNT PER MONTH Average Monthly Gross Receipts from Self-Employment, Business or Businesses Average Net Monthly Income from Self-Employment or Business (Subtract Line 29 from Line 28) ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 7 of 7