Free Rule IX(b) Financial Disclosure Statement.xls - Illinois

STATE of

______________

________________

) ) COUNTY )

IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT ____________ COUNTY, ILLINOIS

IN RE THE MARRIAGE OF: ______________________________, Petitioner, and ______________________________, Respondent.

) ) ) ) ) ) ) )

NO.

___________

IXb FINANCIAL DISCLOSURE STATEMENT OF PETITIONER/RESPONDENT HUSBAND
Name: Address: No. occupants in household: Employer: Occupation: Name: Address: No. occupants in household: Employer: Occupation:

WIFE

CHILDREN Total number of children of this relationship: Of that total number of children, how many reside with? total mother/wife father/husband mother/wife father/husband

Number of other children residing with either parent (Note below)
Note: (do not count children of this relationship at issue)

STATEMENT OF INCOME, EXPENSES, ASSETS & LIABILITIES INCOME HUSBAND GROSS MONTHLY INCOME from: Salary, wages, commissions, bonuses, allowances & overtime
(Note: To arrive at gross monthly income, multiply weekly gross by 4.3 if paid weekly, or multiply bi-weekly income by 2.15 if paid bi-weekly.). . .

WIFE

Pension or retirement Social Security benefits Disability or unemployment benefits Public aid (ADC - Welfare) Child support from prior marriage (alimony) Rents Other income (specify) Other income (specify) Other income (specify) TOTAL GROSS MONTHLY INCOME

............ ............ ............ ............ ............ ............

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ -

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ -

Rule IXb Financial Disclosure

1

revised Jan. 2006

DEDUCTIONS: State income tax withheld ........... Federal income tax withheld ........... Social Security / Medicare withheld (OASDI) . . . . . . . . . . . .................... Medical or other insurance Prior Court Ordered Support Withholding ........... Mandatory Retirement (TRS, IMRF, etc.) ........... Voluntary Retirement (401k, TSP, SIP) ........... .................... Credit Union payments .................... Credit Union savings Union or other dues: (specify) Other deductions (specify) Other deductions (specify) TOTAL MONTHLY DEDUCTIONS

HUSBAND $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ -

WIFE $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ $ -

TOTAL NET MONTHLY INCOME $ No. exemptions claimed: Number of paychecks per year: Filing status: monthly (12) single married semi-weekly (24) other (specify below) bi-weekly (26) weekly (52) EXPENSES

LIST ALL EXPENSES BY MONTH: State the name and relationship of all persons whose expenses are included: _____________________________________________________________________________________________ _____________________________________________________________________________________________

Mortgage or rental payments (residence) ................... Real estate taxes if not included in mortgage payment . . . . . . . . . . . . Real estate insurance if not included in mortgage payment . . . . . . . . Food & household supplies ................... Utilities (gas, electric, water, sewer) ................... Home Telephone .................. ................... Cell Phone .................. ................... Internet .................. ................... Laundry & dry cleaning ................... Clothing (for yourself and family members) ................... Medical (expenses not covered by insurance) . . . . . . . . . . . . . . . . . . Dental (expenses not covered by insurance) ................... Insurance ( do not include payroll deducted items) specify health, dental, disability/accident, life, etc) ___________ . . . . Child Care (babysitters, etc.) ................... School (preschool, college, other schooling expenses) ........... Payment of child/spousal support from prior marriage . . . . . . . . . . . . . . Auto expenses (gas, oil, repairs) ................... Auto insurance ................... Auto payments (exclude payroll deducted) ................... Transportation (other than automobile) ................... Entertainment (clubs, movies, recreation, travel, etc) ........... Incidentals (grooming, gifts, etc.) ................... Installment payments (charges, etc., not previously included) Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ Other monthly expenses (specify) _____________________ TOTAL MONTHLY LIVING EXPENSES

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ -

$__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ -

Rule IXb Financial Disclosure

2

revised Jan. 2006

ASSETS REAL ESTATE: If more than one parcel owned, please attach schedule with following information: Address: Type of property: Date of Purchase: How title held: Mortgage holder Tax amount: ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ $_____________ Original cost: Improvements: Total Costs: Liens: Present market value: EQUITY:(value - liens) $ $ $ $ $ $ -

CERTIFICATES OF DEPOSIT last 4 numbers of cerificate: Where held: _________________________ _________________________ In whose name: Amount: $__________ Maturity Date: _________________________ $__________ Present Value:

last 4 numbers of cerificate: Where held: In whose name: Amount: Maturity Date: Present Value:

______________________ ______________________ $__________ ______________________ $__________

CHECKING AND/OR SAVINGS ACCOUNTS: (Include any IRA accounts or money market accounts) Type of Account Owner Present Balance Names of Institution _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ _______________________ _________________ ______________________ $ PENSIONS, RETIREMENT PLANS: (Includes IRA's, SIP's, 401K Plans, deferred income & profit sharing) Name of company: Name of company: In whose name: In whose name: How many years employed: How many years employed: Present cash value: $__________ Present cash value: $__________ Name & Address of Plan Administrator: Name & Address of Plan Administrator:

STOCKS, BONDS, TREASURY NOTES, BILLS AND OTHER INVESTMENTS: Name of investor: Name of investor: In whose name: In whose name: Present cash value: Present cash value: LIFE INSURANCE AND ANNUITIES: Name of Company: In whose name: Face amount: $__________ Present cash value: $__________ MOTOR VEHICLES: Year Make/Model

Name of Company: In whose name: Face amount: Present cash value:

$__________ $__________

How Title held

Liens $ $ $ $ $

Value $ $ $ $ $

Rule IXb Financial Disclosure

3

revised Jan. 2006

HOUSEHOLD GOODS & FURNISHINGS: (List major items only) ITEM VALUE IN WHOSE POSSESSION _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ ____________________ _____________________________________________________________ $__________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ OTHER ASSETS:
(Interest in a Trust, Stock Options, Deferred Compensation, ATV's, motorcycles, boats, machinery, tools, pending worker's compensation, personal injury or other litigation or collection claims, etc.)

ITEM VALUE IN WHOSE POSSESSION _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ BUSINESS / FARMING INTERESTS:
(List interest in any business, corporation, farms, etc. which you or your spouse have an ownership interest in.)

Name of Business: Form of Ownership: Nature of Business Interest (explain):

Value:

$__________

Name of Company

DEBTS & LIABILITIES For

Balance $ $ $ $ $ $ $

Monthly Payment $ $ $ $ $ $ $

NON-MARITAL PROPERTY CLAIMED BY YOU: (Owned before marriage, gift or inheritance) Item Value Basis of Claim _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ _____________________________________________________________ $__________ ____________________ PREMARITAL AGREEMENT? HEALTH INSURANCE COVERAGE Health insurance coverage currently in effect? Name of insurance carrier: medical Type of insurance: optical per individual Deductible: self Persons covered: employer Provided by: Monthly costs for: $________ self employer cost paid by: employee's contribution: $___________
Rule IXb Financial Disclosure

yes

no

yes dental prescription per family dependents private policy $___________ dependents employee COBRA cost:
4

no

spouse

$___________
revised Jan. 2006

I, the undersigned, declare under penalty of perjury that the foregoing, including attachments, is a true and correct declaration of my assets and liabilities, and that I executed this on the day of 20 . _______________________________ Signature
SUBSCRIBED AND SWORN to before me this

day of

.

NOTARY PUBLIC

Rule IXb Financial Disclosure

5

revised Jan. 2006