Dane County Clerk of Circuit Court FINANCIAL DISCLOSURE STATEMENT Dane County Clerk of Circuit Court This application must be filled out completely ­ PLEASE PRINT. FINANCIAL days of conviction. STATEMENT Applications must be received within ten (10) DISCLOSURELate applications may require a down payment. A $15 fee is charged for the setting up and monitoring of a deferred payment agreement. This be paid at must be filled out completely agreement is established. The fee mustapplicationthe time the deferred payment ­ PLEASE PRINT. Applications must be received within ten (10) days of conviction. Late applications may require a down payment. A $15 fee is charged for the setting up and monitoring of a deferred payment agreement. FOR The fee must be paidTHIS FORM WITH $_____________________ PAYMENT PLAN FEE AND RETURN at the time the deferred payment agreement is established. OFFICE USE ONLY ONLY FOR CASE NUMBERS: OFFICE USE ONLY ONLY CASE NUMBERS: FIRST NAME $_____________________ DOWN PAYMENT BY:____________________________ RETURN THIS FORM WITH $_____________________ PAYMENT PLAN FEE AND DATE $_____________________ DOWN PAYMENT BY:____________________________ M.I. LAST NAME DATE FIRST NAME M.I. ARE YOU KNOWN BY ANY OTHER NAME: WHAT OTHER NAME(S) ARE YOU KNOWN BY? LAST NAME DATE OF BIRTH YES NO ARE YOU KNOWN BY ANY OTHER NAME: WHAT OTHER NAME(S) ARE YOU KNOWN BY?SECURITY NO. (Disclosure of social security numberBIRTH voluntary basis. DATE OF is on a DRIVER'S LICENSE NO. SOCIAL If disclosed, may be used for collection purposes.) YES NO DRIVER'S LICENSE NO. HOME STREET ADDRESS SOCIAL SECURITY NO. (Disclosure of social security number is on a voluntary basis. If disclosed, may be used for collection purposes.) HOME STREET ADDRESS CITY, STATE, ZIP CODE PHONE CITY, STATE, ZIP CODE NAME OF EMPLOYER/BUSINESS RECEIVING THE FOLLOWING: RECEIVING THE FOLLOWING: PHONE CHILD SUPPORT SS SSDI SS VA BENEFITS UNEMPLOYMENT VA BENEFITS UNEMPLOYMENT PENSION NAME OF EMPLOYER/BUSINESS EMPLOYER STREET ADDRESS, CITY, STATE, ZIP PHONE CHILD SUPPORT EMPLOYER STREET ADDRESS, CITY, STATE, ZIP OCCUPATION PENSION NUMBER OF HOURS WORKED PER WEEK SSDI PHONE RATE HOURLY OCCUPATIONLEGAL DEPENDENTS (CHILDREN) NUMBER OF MARITAL STATUS: MARRIED NUMBER OF HOURS WORKED HOURLY RATE IS YOUR SPOUSE/SIGNIFICANT OTHER EMPLOYED? PER WEEK UNMARRIED SEPARATED YES NO IS PAYMENT PLAN WITH THE COURT? DO YOU CURRENTLY HAVE AYOUR SPOUSE/SIGNIFICANT OTHER EMPLOYED? UNMARRIED SEPARATED NUMBER OF LEGAL DEPENDENTS (CHILDREN) EMPLOYMENT: MARITAL STATUS: SPOUSE'S OR SIGNIFICANT OTHER'S PLACE OF MARRIED SPOUSE'S OR SIGNIFICANT OTHER'S PLACE OF EMPLOYMENT: YES YES NO NO DO YOU CURRENTLY HAVE A PAYMENT PLAN WITH THE COURT? 1. TOTAL NET INCOME PER MONTH FROM ALL SOURCES YES NO (Includes spouse or significant other's income) ................................................... $______________ 1. TOTAL NET INCOME PER MONTH FROM ALL SOURCES ALLOWABLE EXPENSES PER MONTH: (Includes spouse or significant other's income) ................................................... $______________ A. HOUSING EXPENSES PER.......................................... + $______________ ALLOWABLE (Rent/Mortgage) MONTH: B. OTHER COURT ORDERED PAYMENTS ...................... + $______________ A. HOUSING (Rent/Mortgage) .......................................... + $______________ (Explain:_____________________________________________________) B. OTHER COURT ORDERED PAYMENTS ...................... + $______________ C. FOOD ................................................................................ $______________ (Explain:_____________________________________________________) 2. C. FOOD ................................................................................ $______________ TOTAL ALLOWABLE EXPENSES (Add lines A, B, C) ........... ($_____________) 3. TOTAL MONTHLY NET ADJUSTED INCOME B, C) ........... ($_____________) 2. TOTAL ALLOWABLE EXPENSES (Add lines A,(Subtract line 2 from line 1) ....... $______________ 4. AMOUNT YOU BELIEVE YOU CAN INCOME MONTH line 2 from line 1) ....... $______________ 3. TOTAL MONTHLY NET ADJUSTED PAY PER (Subtract .................................... $______________ 080-694-4(11/11) 4. AMOUNT YOU BELIEVE YOU CAN PAY PER MONTH .................................... $______________ American LegalNet, Inc. www.FormsWorkFlow.com Powered by TCPDF (www.tcpdf.org) 080-649-4 (11/09) Powered by TCPDF (www.tcpdf.org)