FORM SUMMARY Name of Form: Financial Disclosure Statement Form Number: FA-4139V Statutory Reference: §767.127, Wisconsin Statutes Benchbook Reference: Purpose of Form: This form is used by a party to provide the court and other parties a comprehensive disclosure of their financial situation, including assets, liabilities, income and expenses. Who Completes It: The party providing the disclosure. Distribution of Form: Original will be filed with the court. A copy would be served on the other parties. Accompanying Forms: It is necessary to attach additional schedules, wage statements from your employer for the last 12 weeks showing all income and itemized deductions, state and federal income tax returns for the last two taxable years, and other detailing information that does not fit on the form. Also, if the parties own real estate the full legal description may be required to be attached in a separate document. New Form/Modification: Modification; last update 01/07. Modification: Added disposal of assets language. Comments: The financial disclosures of the parties are confidential documents and must be sealed by the court. About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court’s Office. As a pro se form, its use is NOT mandatory but it is required to be accepted and distributed by the circuit courts of the State of Wisconsin. Date: 01/17/2008 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com PRINT in BLACK ink STATE OF WISCONSIN, CIRCUIT COURT, Enter the name of the county in which this case is filed. Enter the name of the petitioner. If joint petitioners, enter the name of the wife. COUNTY In RE: The marriage of: Petitioner/Joint Petitioner-Wife: First name On the far right, check Petitioner/Joint PetitionerWife or Respondent/Joint Petitioner-Husband Enter the name of the respondent. If joint petitioners, enter the name of the husband. For Official Use Middle name Last name and Financial Disclosure Statement of: Petitioner/Joint Petitioner-Wife Respondent/Joint PetitionerHusband Respondent/Joint Petitioner-Husband: First name Middle name Last name Enter the case number. Case No. This form must be filed with the court within the time period set by the court but no later than 90 DAYS after the service of the Summons and Petition on the respondent (spouse) or the filing of a Joint Petition. Failure by either party to complete and file this form or attachments as required will authorize the court to accept the statement of the other party as the basis for its decisions. Deliberate failure to provide complete disclosure is perjury. 1. PROOF OF INCOME Attach a statement reflecting income earned to date for the current year. Attach most recent W-2 Statement.     2. GENERAL INFORMATION Name Address Address City Phone (day) Alternative Phone: Occupation Employer Address Address City Phone Payroll Office Address Address City Phone State Phone (evening) Social Security Number Zip State Fax Zip State Fax Zip Same as employer FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Page 2 of 8 Case No. ____________ 3. MEMBERS OF YOUR HOUSEHOLD Enter the name and relationship of all people living in your household. Check yes or no to identify if they contribute to payment of household expenses. This person helps pay Relationship Name expenses Yes No I live alone 4. MONTHLY INCOME Income from wages / salary is received (check one): To calculate monthly gross income use the multiplier shown: weekly -multiply weekly income by 4.3 monthly MONTHLY GROSS INCOME every other week (bi-weekly) -multiply bi-weekly income by 2.15 twice a month-multiply semi-monthly income by 2 1. Gross monthly income (before taxes and deductions) from salary and wages, including commissions, allowances and overtime. (See above how to calculate.) Pensions and retirement funds received Social Security benefits received Disability and Unemployment Insurance received Public Assistance Funds received Interest and Dividends received 7. Child Support and maintenance (spousal support) received from any prior marriage/relationship Rental payments received (from property you rent to others) Bonuses received Other sources of income received: (please specify) ¤ ¢ ¥£¡ Total Gross Income (add lines 1-12) MONTHLY DEDUCTIONS 14. Number of tax exemptions claimed 15. Monthly federal income tax withheld 16. Monthly state income tax withheld 17. Social Security 18. Medicare 19. Medical insurance 20. Other insurances 21. Union or other dues 22. Retirement or pension fund 23. Savings plan 24. Credit union 25. Child support or spousal support payments 26. Other deductions: (please specify) 27. 28. Total Monthly Deductions (add lines 14 – 27) MONTHLY NET INCOME (subtract line 28 from line 13) FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Page 3 of 8 Case No. ____________ 5. ANTICIPATED MONTHLY EXPENSES My Monthly Expenses 1. Rent or mortgage payment (primary residence) 2. Real Estate Property taxes (residence) 3. Repairs and maintenance (including maintenance of appliances and furnishings) 4. Food (include eating out) and household supplies 5. Utilities (electricity, heat, water, sewage, trash) 6. Telephone (local, long distance & cellular) 7. Cable and Internet Services 8. Laundry and dry cleaning 9. Clothing and shoes 10. Medical, dental and prescription drug expenses (not covered by insurance) 11. Insurance (life, health, accident, auto, liability, disability, homeowner’s or renter’s- 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. excluding insurance that is paid through payroll deductions) Childcare (babysitting and day care) Child support or spousal support payments (due to previous marriage or relationship) (Exclude payments made through payroll deductions) School expenses (child and adult education) Entertainment (include clubs, social obligations, travel, recreation) Incidentals (grooming, tobacco, alcohol, gifts, holidays and special occasions) Transportation (other than automobile) Auto payments (loans/leases) Auto expenses (gas, oil, repairs, maintenance) Newspapers, magazines, books Care and maintenance of pets (food, vet, grooming) Payments to any dependents not living in your home and not included in a category above (including college age children) Hobbies Other taxes than those listed above (exclude payroll deductions) Other expenses (include expenses of other real properties owned, professional services such as counseling and tax/legal advice, etc) Other Monthly installment payments: Mortgage (other than primary mortgage) Other vehicle payments Credit card debt (total minimum monthly payments) Court ordered obligations Student loans Personal loans TOTAL MONTHLY EXPENSES (Add lines 1-31) FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Page 4 of 8 Case No. ____________ 6. ASSETS: List ALL assets that you own individually and together with your spouse without regard to how they have been or will be divided later. If you do not have assets in an asset category, write “none” under the heading and enter “zero” in the estimated value column. If you need more space, please attach additional sheets. W = Wife H=Husband B=Both Ownership or Title Held by Current Possession Amount Owed Household Items W H B W H B Estimated Value Today Household furniture & accessories Household appliances Kitchen equipment China, silver, crystal Jewelry Clothing Antiques Art Electronic equipment Sports equipment Recreational vehicles, boats Tools Other Automobiles: Year, Make, Model Amount Owed FA-4139V, 01/08 Financial Disclosure Statement Estimated Value Today §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Securities: Stocks, Bonds, Mutual Funds, Commodity Accounts Name of Company & # of shares Life Insurance Name of Company & Policy # Cash and Deposit (Savings and Checking) Accounts Name of Bank or Financial Institution Pension, Retirement Accounts, Deferred Compensation, 401K Plans, IRAs, Profit Sharing, etc. Name of Company & Type of Plan Page 5 of 8 Case No. ____________ Ownership or Title held by W = Wife H=Husband B=Both W H B Value Today Beneficiary Face Amount Cash Value Today Type of Account Account # Last 4 digits Balance Today % Vested if known Date of Valuation FA-4139V, 01/08 Financial Disclosure Statement Value Today §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Business Interests Name of Business & Address Page 6 of 8 W H Type of Business B Other Personal Property Description of Asset Assets Acquired Description of Asset G - Gift I - Inherited B - Before Marriage Real Estate Case No. ____________ % of Ownership Value MINUS Indebtedness Type of Property Ownership W H Value Acquired by B G Parcel 1 I Date Acquired Value Today B Parcel 2 Parcel 3 Type of Property Address: street, city, state Current Fair Market Value Current Mortgage Balance Other Liens FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Financial Disclosure Statement Page 7 of 8 Case No. ____________ 7. MEDICAL, HOMEOWNERS/RENTERS, AUTOMOBILE, OTHER INSURANCE What type of insurance policies do you have? Name of Company, Group # & Policy # W H Date Issued Type of Insurance B 8. DEBTS: List ALL debts that you owe individually and together with your spouse without regard to who will be responsible for payment later. If there are additional DEBTS, please attach a separate sheet of paper with the creditor’s name and address, the type of obligation, who pays (W, H, B) and the current balance. Creditor’s Name & Address Type of Obligation Who Currently Pays W H Monthly Payment Current Balance B FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Case No. ____________ 9. DISPOSAL OF ASSETS Did you dispose of any assets (sold, given away, or destroyed) in the 12 months before the case was filed? No Yes If yes, complete chart below: 5 ') Page 8 of 8 E © 1 Financial Disclosure Statement $ ©  &$ C5 D') 3 4( ) 0( 2 ©  1 ) 3 ) '76 A   @ B''§ 9§ 8 5 ') $ ©  &$ 3 4( 21 ©  )0(   $ $ " '&&%#!¨¦  §  ©§ 10. CURRENT LITIGATION Are you a party in any other lawsuit or litigation? Yes No Yes No If yes, identify the lawsuit or litigation. 11. BANKRUPTCY Have you ever filed for bankruptcy? If yes, identify the following: Type of filing Date of filing Current status 12. DECLARATION I declare under the penalty of perjury that the above, including all attachments, is true and correct as of the date signed below. Signature Sign and print your name. Print or Type Name Enter the date on which you signed your name. Date Note: This signature does not need to be notarized. FA-4139V, 01/08 Financial Disclosure Statement §767.127, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com