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Financial Disclosure Statement FA-4139 - Wisconsin
| Financial Disclosure Statement Form. This is a Wisconsin form and can be used in Family Court Circuit Court Statewide . |
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FORM SUMMARY Name of Form: Form Number: Financial Disclosure Statement FA-4139V Statutory Reference: Benchbook Reference: Purpose of Form: §767.127, Wisconsin Statutes 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. The party providing the disclosure. Original will be filed with the court. A copy would be served on the other parties. 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. Modification; last update 01/07. Added disposal of assets language. The financial disclosures of the parties are confidential documents and must be sealed by the court. 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. Who Completes It: Distribution of Form: Accompanying Forms: New Form/Modification: Modification: Comments: About this Form: 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. For Official Use COUNTY Enter the name of the petitioner. If joint petitioners, enter the name of the wife. In RE: The marriage of: Petitioner/Joint Petitioner-Wife: First name Middle name Last name On the far right, check Petitioner/Joint PetitionerWife or Respondent/Joint Petitioner-Husband and Financial Disclosure Statement of: Respondent/Joint Petitioner-Husband: Petitioner/Joint Petitioner-Wife Respondent/Joint PetitionerHusband Enter the name of the respondent. If joint petitioners, enter the name of the 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 FA-4139V, 01/08 Financial Disclosure Statement State Phone (evening) Social Security Number Zip State Fax Same as employer Zip State Fax Page 1 of 8 Zip §767.127, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material. 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) FA-4139V, 01/08 Financial Disclosure Statement ¤¢ ¥£¡ MONTHLY NET INCOME (subtract line 28 from line 13) §767.127, Wisconsin Statutes Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com This form shall not be modified. It may be supplemented with additional material. 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, repai
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