Wisconsin Financial Disclosure Statement Form
This form functions as the divorcing spouses’ proof of income. Through the fulfillment and filing of this form, the court and both spouses learn about previous and future earnings. The information reflected in this form serves as the basis for the child support arrangement.
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P R IN T i n B LA C K i n k
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l. P age 1 o f 8
E nte r t h e n am e o f t h e
c o unty i n w hic h t h is c ase
i s f ile d .
S TA TE O F W IS C O NSIN , C IR CUIT C O URT,
C O UNTY
E nte r t h e n am e o f t h e
p etitio n er. I f j o in t
p etitio n ers , e n te r t h e n am e
o f t h e w if e .
F or O ff ic ia l U se
O n t h e f a r r ig h t, c h eck
P etiti o n er/J o in t P etiti o n er-
W if e o r R esp onden t/J o in t
P etiti o n er-H usb an d
I n R E: T he m arria ge o f:
P etit io ner/J o in t P etit io ner-W if e :
Fir s t n am e M id dle n am e L ast n am e
a nd
E nte r t h e n am e o f t h e
r e sp ond en t. I f j o in t
p etitio n ers , e n te r t h e n am e
o f t h e h usb an d.
E nte r t h e c ase n u m ber.
R esp onden t/J o in t P etit io ner-H usb an d:
F ir s t n am e M id dle n am e L ast n am e
Fin an cia l D is clo su re
S ta te m en t o f:
P etit io ner/J o in t P etit io ner-W if e
R esp onden t/J o in t P etit io ner-
H usb an d
C ase N o.
T his f o rm m ust b e f ile d w it h th e c o urt w it h in th e tim e p e rio d s e t b y th e c o urt b ut n o la te r t h an 9 0 D AYS a fte r th e s e rv ic e
o f th e S um mon s a n d P etit io n o n th e r e sp o nd ent ( s p o use ) o r th e f ili n g o f a J o in t P etit io n. F ail u re b y e it h er p arty to
c o m ple te a nd f ile t h is f o rm o r a tta ch m ents a s r e qu ir e d w il l a uth oriz e th e c o urt t o a cce pt th e s ta te m ent o f th e o th er p arty
a s th e b asis f o r it s d ecis io ns. D elib era te f a ilu re t o p ro vid e c o m ple te d is clo su re is p erju ry .
1 . P R O OF O F IN CO M E Atta ch a s ta te m ent r e fle ctin g in co m e e arn e d to d ate f o r th e c u rre n t y e ar. Atta ch m ost r e ce nt W -2 S ta te m ent.
2 . G EN ER AL I N FO RM ATIO N
N am e
A ddre ss
A ddre ss
C it y
S ta te Z ip
P ho ne ( d ay)
P ho ne ( e ve nin g)
A lt e rn ativ e P ho ne:
S ocia l S ecu rit y N um ber
O ccu patio n
E m plo ye r
A ddre ss
A ddre ss
C it y
S ta te Z ip
P ho ne
F ax
P ayro ll O ffic e
S am e a s e m plo yer
A ddre ss
A ddre ss
C it y
S ta te Z ip
P ho ne
F ax
Fin ancia l D is c lo su re S ta te m ent Page 2 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 2 o f 8
3 . M EM BER S O F Y O UR H O USEH O LD
E nte r t h e n am e a n d r e la tio nsh ip o f a ll p e ople liv in g in y o ur h o use h old . C heck y es o r n o to id entif y if th e y
c o ntr ib u te t o p aym ent o f h o use ho ld e xp ense s.
N am e
I liv e a lo ne
R ela tio nsh ip T his p ers o n h elp s p ay
e xp en ses
Y es N o
4 . M ONTH LY IN CO M E
I n co m e f r o m w ages / s a la ry is r e ce iv e d ( c h eck o ne):
T o c alc u la te m onth ly g ro ss in co m e u se t h e m ult ip lie r s h ow n:
w eekly - m ult ip ly w eekly in co m e b y 4 .3 e ve ry o th er w eek ( b i- w eekly ) - m ult ip ly b i- w eekly in co m e b y 2 .1 5
m onth ly t w ic e a m onth -m ult ip ly s e m i- m onth ly in co m e b y 2
M ONTH LY G RO SS IN CO M E
1 . G ro ss m onth ly in co m e ( b efo re ta xe s a nd d eductio n s) fr o m s a la ry a nd w ages,
i n clu din g c o m m is sio ns, a ll o w ance s a n d o ve rtim e. ( S ee a bo ve h o w to c a lc u la te .)
Pensio ns a nd r e tir e m ent f u nds r e ce iv e d
Socia l S ecu rit y b en efit s r e ce iv e d
Dis a b il it y a n d U nem plo ym ent In su ra nce r e ce iv e d
Pub lic A ssis ta nce F unds r e ce iv e d
In te re st a nd D iv id en ds r e ce iv e d
7 . C hil d S upp ort a n d m ain te nance ( s p ousa l s u pp ort) r e ce iv e d f r o m a n y p rio r
m arr ia ge/r e la tio nsh ip
Renta l p aym ents r e ce iv e d ( fr o m p ro perty y o u r e nt t o o th ers )
Bon use s r e ce iv e d
Oth er s o urc e s o f in co m e r e ce iv e d: ( p le ase s p ecif y )
T ota l G ro ss In co m e ( a d d lin es 1 -1 2)
M ONTH LY D ED UCTIO NS
14. Num ber o f ta x e xe m ptio ns c la im ed
15. Month ly f e dera l in co m e ta x w it h held
1 6. Month ly s ta te in co m e ta x w it h h eld
1 7. Socia l S ecu rit y
1 8. Med ic a re
1 9. Med ic a l in su ra nce
2 0. Oth er in su ra nce s
2 1. Unio n o r o th er d ues
2 2. Retir e m ent o r p ensio n f u nd
2 3. Savin gs p la n
2 4. Cre dit u n io n
2 5. Child s u p port o r s p ousa l s u pport p aym ents
2 6. Oth er d e ductio ns: ( p le ase s p ecif y )
2 7.
2 8. Tota l M on th ly D ed uctio n s ( a d d lin es 1 4 – 2 7)
MONTH LY N ET IN CO M E ( s u btr a ct lin e 2 8 f r o m lin e 1 3)
Fin ancia l D is c lo su re S ta te m ent Page 3 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 3 o f 8
5 . A N TIC IP ATE D M ONTH LY E XP EN SE S
M y M onth ly E xp en se s
1.
Rent o r m ortg age p a ym ent ( p rim ary r e sid ence )
2 .
Real E sta te P ro perty t a xe s ( re sid ence )
3 .
Repa ir s a nd m ain te na nce ( in clu d in g m ain te na nce o f a p pli a nce s a nd f u rn is h in gs)
4 .
Food ( in clu de e atin g o ut) a nd h ouse h old s u pp li e s
5 .
Util it ie s ( e le ctr ic it y , h eat, w ate r, s e w age, tr a sh )
6 .
Tele pho ne ( lo ca l, lo ng d is ta nce & c e ll u la r)
7 .
Cable a nd I n te rn et S erv ic e s
8 .
Laun dry a nd d ry c le a nin g
9 .
Clo th in g a nd s h o es
1 0.
Med ic a l, d e nta l a n d p re scrip tio n d ru g e xp ense s ( n ot c o ve re d b y in su ra nce )
1 1.
In su ra nce ( lif e , h e alt h , a ccid ent, a uto , lia bilit y , d is a bilit y , h om eow ner’s o r r e n te r’s -
e xclu din g in su ra nce th at is p aid th ro ugh p a yro ll d ed uctio ns)
1 2.
Child ca re ( b ab ys it t in g a n d d a y c a re )
1 3.
Child s u p port o r s p ousa l s u pport p aym ents ( d ue to p re vio us m arria ge o r r e la tio nsh ip )
( E xclu de p a ym ents m ade t h ro ug h p a yro ll d ed uctio ns)
1 4.
Sch oo l e xp ense s ( c h ild a nd a du lt e duca tio n)
1 5.
Ente rta in m ent ( in clu d e c lu b s, s o cia l o blig atio ns, tr a ve l, r e cre atio n)
1 6.
In cid e nta ls ( g ro om in g, t o ba cco , a lc o h ol, g if ts , h o li d a ys a nd s p ecia l o cca sio ns)
1 7.
Tra nsp orta tio n ( o th er th a n a uto m obil e )
1 8.
Auto p a ym ents ( lo ans/le ase s)
1 9.
Auto e xp e nse s ( g as, o il, r e pair s , m ain te n ance )
2 0.
New sp ap ers , m aga zin es, b ooks
2 1.
Care a n d m ain te n ance o f p ets ( fo od, v e t, g ro om in g)
2 2.
Paym ents to a n y d epe nde nts n ot li v in g in y o ur h om e a nd n ot in clu ded in a c a te go ry
a bo ve ( in clu din g c o lle ge a g e c h ild re n)
2 3.
Hobb ie s
2 4.
Oth er ta xe s th an t h ose lis te d a b ove ( e xclu d e p ayro ll d e ductio ns)
2 5.
Oth er e xp e nse s ( in clu de e xp ense s o f o th er r e a l p ro pertie s o w ned , p ro fe ssio n al
s e rv ic e s s u ch a s c o unse lin g a n d ta x/le g al a d vic e , e tc )
Oth er M onth ly in sta llm ent p a ym ents :
2 6.
Mortg a ge ( o th er t h an p rim ary m ortg age)
2 7.
Oth er v e hic le p a ym ents
2 8.
Cre dit c a rd d e bt ( to ta l m in im um m onth ly p a ym ents )
2 9.
Court o rd ere d o b lig atio ns
3 0.
Stu d ent lo ans
3 1.
Pers o na l lo a ns
TO TA L M ONTH LY E X PEN SES ( A dd lin es 1 -3 1)
Fin ancia l D is c lo su re S ta te m ent Page 4 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 4 o f 8
6 . A SSETS : L is t A LL a s sets t h at y o u o w n in div id uall y a n d t o geth er w it h y o ur s p ouse w it h out r e g ard t o h ow
th ey h av e b een o r w ill b e d iv id ed la te r.
If y o u d o n ot h ave a ss ets in a n a s set c ate g ory , w rit e “ n one” u nder t h e h ead in g a n d e n te r “ ze ro ” in t h e
e stim ate d v alu e c o lu m n. If y o u n eed m ore s p ace, p le ase a tta ch a d dit io nal s h eets .
W = W if e H =H usb an d
B =B oth
O w ners h ip o r
T it le H eld b y
C urre n t
P oss essio n
H ouseh old It e m s
W H B W H B
Am ount O w ed
E stim ate d
V alu e
T oday
H ouse h old f u rn it u re & a cce sso rie s
H ouse h old a p plia nce s
K it c h en e qu ip m ent
C hin a, s ilv e r, c ry s ta l
Je w elr y
C lo th in g
A ntiq u es
A rt
E le ctr o nic e qu ip m ent
S ports e qu ip m ent
R ecre atio na l v e h ic le s, b oa ts
T ools
O th er
A uto m obile s:
Y ear, M ake , M odel
A m ount O w ed
E stim ate d
V alu e
T oday
Fin ancia l D is c lo su re S ta te m ent Page 5 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 5 o f 8
O w ners h ip o r T it le h eld b y
W = W if e H =H usb an d
B =B oth
S ecu rit ie s: S to ck s, B ond s, M utu al
F unds, C om modit y A cco unts
N am e o f C om pan y & # o f s h are s
W H B
V alu e
T oday
L if e In su ra n ce
N am e o f C om pan y & P olic y # B en efic ia ry F ace A m ount C ash V alu e
T oday
C ash a n d D ep osit ( S av in gs a n d
C heckin g) A cco unts
N am e o f B ank o r F in ancia l In stit u tio n
T yp e o f
A cco unt
A cco unt #
Last 4 d ig it s
B ala n ce
T oday
P en sio n, R etir e m en t A cco unts ,
D efe rre d C om pen satio n, 4 01K
Pla n s, IR As, P ro fit S harin g, e tc .
N am e o f C om pan y & T yp e o f P la n
% V este d
if k n ow n D ate o f V alu atio n V alu e
T oday
Fin ancia l D is c lo su re S ta te m ent Page 6 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 6 o f 8
B usin es s In te re sts
N am e o f B usin ess & A ddre ss W H B Typ e o f
B usin es s % o f O w ners h ip V alu e M IN US
In deb te d ness
O th er P ers o nal P ro perty
D escrip tio n o f A sse t T yp e o f
P ro perty V alu e
O w ners h ip A cq u ir e d b y D ate A cq uir e d V alu e T oday A ssets A cq uir e d
D escrip tio n o f A sse t
G - G if t
I - In herit e d
B - B efo re M arria g e
W H B G I B
R eal E sta te P arc el 1 P arc el 2 P arc el 3
T yp e o f P ro perty
A ddre ss: s tr e et, c it y , s ta te
C urre nt F air M ark e t V alu e
C urre nt M ortg a ge B ala nce
O th er L ie ns
Fin ancia l D is c lo su re S ta te m ent Page 7 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 7 o f 8
7. M ED IC AL, H O M EO W NER S/R EN TE R S, A U TO M OBIL E , O TH ER IN SU R AN CE
W hat t y p e o f in su ra n ce p olic ie s d o y o u h av e?
N am e o f C om pan y, G ro u p # & P olic y # W H B Typ e o f
In su ra n ce
D ate Is su ed
8 . D EB TS : L is t A LL d eb ts t h at y o u o w e in div id ually a n d t o geth er w it h y o u r s p ouse w it h out r e g ard t o w ho w ill
b e r e sp onsib le f o r p aym en t la te r.
If th ere a re a dd it io na l D EB TS , p le ase a tt a ch a s e para te s h eet o f p ap er w it h th e c re dit o r’s n am e a nd a d dre ss, th e t y p e
o f o bli g atio n , w ho p ays ( W , H , B ) a nd th e c u rre nt b ala nce .
W ho C urre n tly
P ays C re d it o r’s N am e & A dd re ss T yp e o f
O blig atio n W H B
M onth ly
P aym en t
C urre n t
B ala n ce
Fin ancia l D is c lo su re S ta te m ent Page 8 o f 8 Case N o. _ _____ ______
FA -4 13 9V , 0 1/0 8 F in a ncia l D is clo su re S ta te m ent §76 7.1 27 , W is co nsin S ta tu te s T h is f o rm s h all n ot b e m odif ie d . It m ay b e s u pple m en te d w it h a d dit io nal m ate ria l.
P age 8 o f 8
9 . D IS PO SA L O F A SSETS
D id y o u d is p ose o f a n y a sse ts ( s o ld , g iv e n a w ay, o r d e str o ye d) in t h e 1 2 m onth s b efo re th e c a se w as f ile d?
Y es N o
I f y es, c o m ple te c h art b elo w :
"!
# $% !
'&
(
*) #,+
-
"!
#
10. C U RREN T L IT IG ATIO N
A re y o u a p arty in a n y o th e r la w su it o r lit ig a tio n?
Y es N o
I f y es, id entif y th e la w su it o r lit ig atio n.
1 1. B AN KRU PTC Y
Have y o u e ve r f ile d f o r b an kru ptc y?
Y es N o
I f y es, id entif y th e f o ll o w in g :
T yp e o f f ilin g
D ate o f f ilin g
C urre nt s ta tu s
1 2. D EC LA R ATIO N
I d ecla re u nder t h e p en alt y o f p erju ry t h at t h e a b ove , in clu din g a ll a tta c h m en ts , i s t r u e
a n d c o rre c t a s o f t h e d ate s ig ned b elo w .
S ig n a n d p rin t y o ur n am e.
E nte r t h e d ate o n w hic h y o u
s ig n ed y o ur n am e.
N ote : T his s ig n atu re d oes
n ot n eed t o b e n ota riz ed .
S ig n atu re
P rin t o r T yp e N am e
D ate
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