CODE:_______ ______________________ Nevada Bar No. _________ ______________________ ______________________ Attorney for ____________ IN THE FAMILY DIVISION OF THE ___________________ JUDICIAL DISTRICT COURT IN AND FOR THE COUNTY OF________, STATE OF NEVADA _____________________________ 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:______ To: ______ Previously Employed by:_________________________ 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 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______________________ Signature_______________________________________ ADKT 388 Exhibit B NRCP 16.2 Financial Disclosure Form Page 1 of 7 Nevada Supreme Court Revised: October 18, 2007 American LegalNet, Inc. www.FormsWorkFlow.com Case No._______ Dept. No. ______ 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 1 $________ + insurance $_________ = Utilities: Gas/Oil $____________ + electricity $_________ + TV/cable $___________ + 2 water $__________ + garbage $ ________= Telephone: landline $_________ + cellular $________ + Internet $_________+ fax 3 $________ + other $__________= 4 Food, Groceries & Incidentals (not including entertainment or dining out) Transportation: monthly payment/lease $________ + gas and oil $______ + repairs and 5 maintenance, tires $_______ + insurance $_______ + license/registration; $________ + parking $________ + public transportation $_________ + other $________= 6 7 House Maintenance: housekeeping $________ + garden/lawn care $_______ + snow removal $_________ + repairs & maintenance $_______ + other $_______ = TOTAL AMOUNT Entertainment: dining out $_______ + movies, shows $_______ + music/videos $________ + other $_______ = Dues, Memberships, Fees: Professional $_______ + memberships (health club country 8 club) $_______ + homeowners $_______ + fraternal $_______ + business $_______ + other $_______ = Health/exercise: clothing/shoes $______ + fees/passes (health clubs etc.) $______ + other 9 $______ = 10 Clothing: self $______ + children $______ + cleaning $______ = 11 Vacations Pets: Food $_____ + boarding $______ + healthcare $_____ + grooming $______ + other $______ = Healthcare: Insurance $_______ + unreimbursed; medical $_____+ dental $_____ + 13 orthodontic $______ + medications $______ + counseling $_____ + physical therapy $________ + chiropractic $______ + other $______ = Appearance: hair $______ + nails $______ + facials/massage $______ + cosmetics 14 $______ + other $______ = 12 15 Insurance: life $______ + disability $______ + other $______ = 16 Books, Newspapers & Magazines 17 Church/Charitable 18 Accounting & Tax Preparation 19 20 21 Support of Others: Ordered Child Support $________+ voluntary child support $______ + court ordered spousal support $______ + eldercare $______ = Miscellaneous: Gifts $______ + storage $______ + flowers $_____ + savings $______ +Lawyers fees $________ +Other $______ = Education:Tuition, Books & Fees $______ + extracurricular $______ + sports $______ + music $_______ + other $________ = 22 Childcare: day care $________ + preschool $________ + other $_______ = Minimum Charge Card Payments and other consumer/installment debt: credit card #1 23 $_______ + credit card #2 $_______ + credit card #3 $________+ credit card #4 $_______+ other debt $_______= 24 TOTAL MONTHLY EXPENSES (Add lines 1-23 above) ADKT 388 Exhibit B NRCP 16.2 Financial Disclosure Form Page 3 of 7 Nevada Supreme Court Revised: October 18, 2007 American LegalNet, Inc. www.FormsWorkFlow.com Case No..______ Dept No._______ PERSONAL INCOME SCHEDULE IF SELF-EMPLOYED OR BUSINESS OWNER PLEASE FILL IN THE BUSINESS INCOME/EXPENSE SCHEDULE YOUR OWN INCOME AMOUNT EMPLOYMENT INCOME (if paid weekly multiply by 52 and divide by 12; if paid every two weeks, multiply by 26 and divide by 12) Average Gross Monthly Income from Employment (all employment income including salary $__________+ bonuses $__________ + overtime $__________ + commissions $____________ + tips 1 $___________ + other $__________) = Average Monthly Paycheck Deduction-Income Taxes Average Monthly Paycheck Deduction-Social Security Average Monthly Paycheck Deduction-Medicare Average Monthly Paycheck Deduction-Health Insurance Average Monthly Paycheck Deduction-Retirement Plan or 401(k) Average Monthly Paycheck Deduction-Savings Account Average Monthly Paycheck Deduction(s)-Other NOTE: ATTACH COPIES OF YOUR THREE MOST RECENT PAY STUBS. 2 3 4 5 6 7 8 9 10 Total Paycheck Deductions per Month (Add lines 2-8 above) Average Net Monthly Income from Employment (Subtract line 9 from line 1) OTHER INCOME 11 12 13 Monthly Spousal Support/Alimony Awarded by a Court Monthly Child Support: court ordered $_______ + other/voluntary child support $_______= Investment Income (Dividends, interest and capi