JD-1718, 02/18 Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE INTEREST OF Name Date of Birth Statement of Income, Assets, Debts and Living Expenses Case No. Under penalty of perjury, I state that the following information on this financial statement is true, accurate and complete: Print Name of Person Completing Form Name of Parent 1 's Employer Number of People in Household Adults Children Name of Parent 2 's Employer STATEMENT OF MONTHLY HOUSEHOLD INCOME (If there are insufficient columns for all household members, attach additional schedules.) Parent 1 [Name] Parent 2 [Name] Other House - hold Members Salary and wages (If weekly or biweekly, compute as a monthly figure.) Other income: (Pensions, retirement, social security, disability, worker's compensation, public assistance) Child support and/or maintenance from prior spouse Dividends, interest, rents, bonuses Other: Total Monthly Income Itemized mandatory monthly deductions: (Do not include savings or credit union deductions not required by law.) Federal and state income taxes, social security, Medicare Union or other dues Retirement and pension funds Other mandatory monthly deductions: Total Mandatory Monthly Deductions Net Monthly Income STATEMENT OF ASSETS Asset Description Fair Market/ Cash Value Real estate (List kind of property and location) Other real estate (List kind of property and location) Vehicle (Give year and make) Other vehicles (Give year and make) Checking account (Give name of financial institution) Savings account (Give name of financial institution) IRA/Pensions/Profit Sharing (Identify by name) Life insurance with cash value (Identify by name of company) Stocks/Bonds/Certificates of Deposit Other assets valued over $200 Total Value of Assets American LegalNet, Inc. www.FormsWorkFlow.com JD-1718, 02/18 Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 LONG TERM DEBTS AND MONTHLY EXPENSES Long Term/Installment Debts Creditor Name Balance Owed Monthly Payment Mortgage Payment (Include property taxes and insurance if included in payment.) Credit Cards Automobile Loans Other: Other: Other: Total Owed Other Monthly Debts/Expenses Rent (Do not duplicate mortgage payment above.) Repairs/maintenance on home Food Electricity/water/heat Telephone Laundry and dry cleaning Child support paid for children not in your home Maintenance paid to an ex - spouse Clothing and shoes Health insurance premiums Medical/dental/drug expenses not covered by insurance Life insurance premiums Other insurance premiums (specify): Child care Cable TV Transportation costs (oil/gas/commuting) School Entertainment/incidentals/newspapers/books/periodicals Hobbies Other: Other: Other: Total Monthly Payments Complete this form and return it to the juvenile court clerk so that it arrives by the time indicated on the court order. Signature Telephone Number Date Signed American LegalNet, Inc. www.FormsWorkFlow.com