IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS IN RE THE MARRIAGE OF: PETITIONER AND NO. ______-D-________________ RESPONDENT FINANCIAL STATEMENT GROSS INCOME 1. GROSS WAGES OR SALARY 2. ADDITIONAL INCOME (State Source) 3. (add lines 1 and 2) TOTAL GROSS INCOME PER MONTH DEDUCTIONS 4. FICA (Social Security Tax) 5. Federal Tax Withholding 6. State Tax Withholding 7. Union Dues 8. Mandatory Retirement Deductions 9. Health & Hospital Insurance Premiums 10. Installment debt payments for medical bills 11. Court-ordered Child Support & Maintenance Case # County & State 12. Necessary Expenses for Production of Income 13. 14. (add lines 4 thru 12) (subtract line 13 from line 3) TOTAL DEDUCTIONS NET INCOME PER MONTH Exemptions Claimed 15. PAY PERIOD 16. TAX FILING STATUS PRINT NAME ADDRESS CITY, STATE, ZIP American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS HOUSING EXPENSES 17. Rent or mortgage Payments 18. Homeowner's or Rental Insurance 19. Real Estate Taxes 20. Repairs and Maintenance of Home 21. 22. 23. (Guidelines: 20% first 2 children; 5% each addl child) (subtract line 22 from line 21 and enter here) TOTAL HOUSING CHILDREN'S SHARE YOUR SHARE UTILITIES 24. Gas 25. Water 26. Electricity 27. Telephone 28. Cable TV and Satellite Fees 29. Trash Service 30. Sewer 31. 32. 33. (Guidelines: 20% first 2 children; 5% each addl child) (Subtract line 32 from line 31 and enter here) TOTAL UTILITIES CHILDREN'S SHARE YOUR SHARE TRANSPORTATION 34. Gasoline 35. Maintenance and Repairs 36. Registration (plates) 37. Auto Insurance 38. Payment on Auto Loan 39. 40. 41. (Guidelines: 20% first 2 children; 5% each addl child) (Subtract line 40 from line 39 and enter here) TOTAL TRANSPORTATION CHILDREN'S SHARE YOUR SHARE INSURANCE (NOT Auto or Health) 42. Life Insurance Premiums (total of line 71; monthly average) 43. Dental Insurance Premiums 44. Other Insurance Premiums (describe) 45. 46. 47. (List Children's actual portion of premium) (Subtract line 46 from line 45 and enter here) TOTAL INSURANCE CHILDREN'S SHARE INSURANCE YOUR SHARE INSURANCE American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS YOURS 48. Food 49. Clothing 50. Medical and Dental Care, Glasses and Drugs 51. Recreation 52. Laundry and Cleaning 53. Hair Care 54. School Expenses and School Lunches 55. Day Care Center or Baby Sitter 56. Charitable and Religious Contributions 57. Other Expenses (Attach sheet and enter total here) 58. 59. 60. (Add lines 23, 33, 41, 47 and 48 thru 57) CHILDREN YOUR TOTAL EXPENSES CHILDREN'S TOTAL EXPENSES RELATED DEBT MARKET VALUE EQUITY (Add lines 22, 32, 40, 46, and 48 thru 57) REAL ESTATE: MORTGAGE HOLDER 61. MOTOR VEHICLES LOAN HOLDER RELATED DEBT MARKET VALUE EQUITY 62. HOUSEHOLD AND PERSONAL GOODS OVER $300 EACH LOAN HOLDER RELATED DEBT MARKET VALUE EQUITY TOTAL OF GOODS LESS THAN $300 EACH American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS 63. RETIREMENT, PENSION, PROFIT SHARING PLANS AND IRA'S Begin & End Dates Number of Months Married Number of During Accrual Months of Accrual NAME OF COMPANY Current Value 64. NAME OF COMPANY STOCKS, BONDS, MUTUAL FUNDS NO. SHARES PURCHASE DATE NAME(S) OF OWNER(S) CURRENT VALUE 65. BANK & ACCT. NO. BANK AND SAVINGS AND LOAN ACCOUNTS NAMES CD VALUE SAVINGS CHECKING 66. 67. CASH IN YOUR POSSESSION OR CONTROL> LAWSUITS AND WORKMAN'S COMPENSATION CLAIMS -- PENDING OR TO BE FILED CASE NO. COUNTY, STATE TYPE OF ACTION AMOUNT CLAIMED NAME OF DEFENDANT 68. NAME OF DEBTOR MONEY OWED TO YOU RELATIONSHIP TO YOU DATE LOAN MADE DUE DATE CURRENT AMOUNT American LegalNet, Inc. www.FormsWorkFlow.com IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS 69. DEBTS OWED TO FRIENDS OR RELATIVES NAME OF FRIEND OR RELATIVE RELATIONSHIP TO YOU PURPOSE OF DEBT DUE DATE CURRENT BALANCE 70. DEBTS OTHER THAN DEBT RELATED TO ABOVE PROPERTY NAME OF CREDITOR DATE OF LOAN PURPOSE DATE DUE AMOUNT 71. NAME OF COMPANY LIFE INSURANCE OWNER INSURED POLICY NUMBER FACE VALUE CASH VALUE MISCELLANEOUS INFORMATION I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, THAT THE FOREGOING INFORMATION IN THIS FINANCIAL STATEMENT IS TRUE AND CORRECT. ______________________________________ YOUR SIGNATURE Subscribed and sworn to before me, the undersigned Notary Public, on this ______ day of _____________, 20____. My Commission expires ________________. ______________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR FINANCIAL STATEMENT MONTHLY AVERAGES - USE MONTHLY AVERAGES FOR ALL FIGURES - There are 4.33 weeks in an average month. For example, if you have a weekly amount for your income, multiply it by 4.33 to convert it to monthly. If you have a figure for two weeks, multiply it by 26 and divide by 12. TRY TO PREDICT THE FUTURE - Based on your current expenses and your future needs do your best to estimate your expenses for the period after the divorce. CHILDREN'S EXPENSES - Fill in items relating to children only if you will have, or expect to have, minor children living with you and only if you have a legal obligation to support them. Do not include children over 18 if there is a request for educational expenses or if the children have mental or physical disabilities. If there is a claim for educational expenses, attach written information from the school relating to the expense claimed. Also attach written responses to applications for scholarships and grants. The other exception relates to insurance premiums. See instructions for items 42, 43, 44. ATTACHMENTS RELATING TO INCOME - You must attach the following to your Financial Statement: all pages and W-2 forms of your last-filed Federal Income Tax Return; a current pay stub showing your year-to-date earnings and deductions. FAIR MARKET VALUE (FMV) - Fair market value is defined as an amount that a buyer would pay for the item in it's current condition in a normal market such as newspaper want ads, a used car log, comparable real estate sales, or auction. FMV of a used item is not what you paid for it when it was new, although that price can be used as guidance. NO DUPLICATION OF EXPENSES - Do not duplicate expenses. For example, do not list dental insurance on item 9 and then list it again on item 43
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