Declaration of Disclosure of Assets, Debts, Income, and Expenses

In the case of spouses going through a divorce case in the State of Montana wanting to declare their financial status to reach a marital settlement agreement, the following form has to be completed and submitted.

Extracted Text for Proper Search

Declaration of Disclosure, Page 1 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
_______________________________
Name
_____________________________________
Address
_____________________________________
City State  Zip Code
_____________________________________
Phone Number
[ ] PETITIONER/[ ] RESPONDENT PRO SE
MONTANA _______________ JUDICIAL DISTRICT COURT
_____________________ COUNTY
In re the Marriage of: 
________________________,
 Petitioner,
and
________________________,
Respondent.Cause No.: _________________ 
[ ] Petitioner’s/[ ] Respondent’s
[ ] Preliminary/[ ] Final
Declaration of Disclosure of Assets,
Debts, Income, and Expenses
Warning: Montana law, M.C.A. § 40-4-252, requires the full disclosure of all assets, debts,
income, and expenses.  Failure of either party to file a complete financial disclosure statement
shall authorize the Court to accept the statement of the other party as accurate.  Any
deliberately false statement made hereon or on any schedules or attachments may subject you
to the penalty of perjury or other appropriate relief and may be considered a fraud upon the
Court.
If you need additional space on which to list your assets, debts, income, or expenses, please attach
additional sheets of paper as necessary.  Do not write in the margins or on the reverse sides of the
pages of this document.

Declaration of Disclosure, Page 2 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
1. Disclosure of Assets	
a. Real Estate
Description	
Est imat ed Value	Name(s) on Title	
Address: ___________________________________
Legal Description:____________________________
___________________________________________
Is there a secured debt on the property? [ ] Yes [ ] No
If yes, amount owed: __________ As of:      /     /     
Lender: ____________________________________
Address: ___________________________________
Legal Description:____________________________
___________________________________________
Is there a secured debt on the property? [ ] Yes [ ] No
If yes, amount owed: __________ As of:      /     /     
Lender: ____________________________________
b. Vehicle(s)
Description	
 Est imat ed Value 	Name(s) on Title	
Year/Make/Model: ___________________________
VIN#: _____________________________________
Is there an outstanding loan on the vehicle? 
[ ] Yes [ ] No   If yes, amount owed: _____________
As of:      /     /     	
 Lender: _____________________
Year/Make/Model: ___________________________
VIN#: _____________________________________
Is there an outstanding loan on the vehicle? 
[ ] Yes [ ] No   If yes, amount owed: _____________
As of:      /     /     
 Lender: _____________________

Description	 Est imat ed Value 	Name(s) on Title	
Declaration of Disclosure, Page 3 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
Year/Make/Model: ___________________________
VIN#: _____________________________________
Is there an outstanding loan on the vehicle? 
[ ] Yes [ ] No   If yes, amount owed: _____________
As of:      /     /     	
 Lender: _____________________
Year/Make/Model: ___________________________
VIN#: _____________________________________
Is there an outstanding loan on the vehicle? 
[ ] Yes [ ] No   If yes, amount owed: _____________
As of:      /     /     
 Lender: _____________________
c. Bank Accounts and Cash
Description	
 (include name of bank and account 
number)Balance as of	
     /     /      	
Name(s) on
Account	
Cash XXXXXXXX
d. Pensions/Retirement Accounts; Life Insurance (Cash Value); Stocks, Bonds,
Secured Notes, Mutual Funds
Description	
Est imat ed Value	Name(s) on
Account

Declaration of Disclosure, Page 4 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02	
e. Personal Property (including appliances, furniture, jewelry, art, guns, etc.)
Description	
Est imat ed  Value

Declaration of Disclosure, Page 5 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02	
f. Business Interests (including equipment, tools, livestock, etc.)
Description	
Est imat ed 
Value	
Name(s) on Title	
g. Other Assets
Description	
Est imat ed 
Value 	
Name(s) on Title	
2. Disclosure of Debts
Description	Creditor	Amount
Owed	
Name on Debt	
Secured Debt on Real
Property(See 1(a) above) XXXXX XXXXXXXXX
Vehicle Loan(s) (See 1(b) above)XXXXX XXXXXXXXX
Ut ilit y Bill(s):

Description	Creditor	Amount
Owed	
Name on Debt	
Declaration of Disclosure, Page 6 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
Credit Card(s):
Student Loan(s):
Medical Expenses:
Ot her Liabilit ies:
3. Disclosure of Income	
The [ ]Petitioner/ [ ]Respondent has the following income:
Source of Income	
Amount per Month	
Gross Wages, Salary, Commissions
Rents, Interests, Dividends
Self Emplo yment  Earnings
Unemployment or Worker’s Compensation
Social Security Benefits, including SSI
Public Assistance
Food Stamps

Source of Income	Amount per Month	
Declaration of Disclosure, Page 7 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
Pension, Retirement
Child Support
Dependent’s Benefits
Other Income (describe):
4. Disclosure of Expenses	
The [ ] Petitioner/[ ] Respondent has the following expenses:
Description of Expense	
Amount per Month	
Taxes and other money withheld from income
Retirement
Health Insurance (self and children)
Medical Expenses 
Housing (rent or mortgage payment)
Property Taxes
Property Insurance
Transportation
Car Insurance
Student Loans
Ut ilit ies
Telephone
Clothing
Food and Household Supplies
Child Care

Description of Expense	Amount per Month	
Declaration of Disclosure, Page 8 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02
Child Support Payments
Other Expenses (describe):
DATED this ____ day of _______________________, 20___.
                                                                   	
Signature
                                                                   
Print  Name
[ ]Petitioner/ [ ]Respondent Pro Se
STATE OF MONTANA )
) ss.
COUNTY OF                                  	
)
SUBSCRIBED AND SWORN TO before me this _____ day of ____________________,
20____.
                                                                      	
Name (printed): _______________________
(Seal) Notary Public for the State of Montana
Residing at                                                    
My commission expires