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Financial Disclosure Statement Of Petitioner-Respondent 9(b) - Illinois
| Financial Disclosure Statement Of Petitioner-Respondent Form. This is a Illinois form and can be used in Civil Rock Island Local County . |
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STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE FOURTEENTH JUDICIAL CIRCUIT, _________________________ COUNTY COUNTY, ILLINOIS IN RE THE MARRIAGE OF: PETITIONER, And NO. RESPONDENT FINANCIAL DISCLOSURE STATEMENT OF PETITIONER/RESPONDENT HUSBAND WIFE Name:_____________________________ Name:_________________________ Address:___________________________ Address:________________________ ___________________________ _______________________ Soc. Sec. #_________________________ Soc. Sec. #_____________________ _ Date of Birth:________________Age____ Date of Birth:___________Age_____ Employer:__________________________ Employer:______________________ Occupation:_________________________ Occupation:_____________________ CHILDREN NAME DATE OF BIRTH AGE WITH WHOM RESIDING ___________________ _______________ ______ _____________________________ ___________________ _______________ ______ _____________________________ ___________________ _______________ ______ _____________________________ STATEMENT OF INCOME, EXPENSES, ASSETS & LIABILITIES INCOME GROSS MONTHLY INCOME FROM: HUSBAND WIFE Salary, wages, commissions, bonuses, Allowances & overtime (Note: To arrive At gross monthly income, multiply weekly Bi-weekly income by 2.15 if paid bi-weekly) $__________ $___ ______ Pension or retirement $__________ $_________ 1 FORM 9(b) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 INCOME HUSBAND WIFE Social Security benefits $_________ $_______ Disability or unemployment benefits $_________ $_______ Public Aid (ADC-Welfare) $_________ $_______ Child Support from prior marriage (alimony) $_________ $_______ Rents $_________ $_______ Other Income (specify) ____________________ $_________ $_______ ____________________ $_________ $_______ TOTAL GROSS MONTHLY INCOME $_________ $_______ DEDUCTIONS: State income tax withheld $_________ $_______ Federal income tax withheld $_________ $_______ Social Security withheld $_________ $_______ Medical or other insurance $_________ $_______ Credit Union payments $_________ $_______ Credit Union savings $_________ $_______ Union or other dues $_________ $_______ Other deductions (specify) $_________ $_______ Number of paychecks per year: 12 24 26 52 Number of Exemptions claimed: _______________ Filing status:_______single_______married________other TOTAL MONTHLY DEDUCTIONS $_________ $_______ TOTAL NET MONTHLY INCOME $_________ $_______ MONTHLY LIVING 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 inuded icln mortgage payment--------------------- $___________________________ Real estate insurance if not iclnuded in mortgage payment---------------- $___________________________ Food & household supplies-----------------------------------------------------$_________________ __________ Utilities (gas and electric-heat)-------------------------------------------------$________________ ___________ Water-------------------------------------------------------------------------------$___________________________ Teleratphone (base e only)------------------------------------------------------$_______________ ____________ Cable T.V.-------------------------------------------------------------------------$___________________________ Laundry & drycl eaning---------------------------------------------------------$____________ _______________ Clothing (for yoursel& famf ily member)------------------------------------ $___________________________ Medical (expenses notovered by c insurance)------------------------------- $___________________________ Dental (expenses notovered by c insurance)--------------------------------- $___________________________ Insurance (health, accident, life) EXCLUDE PAYROLL DEDUCT----- $___________________________ Child Care (babysitters, etc.)--------------------------------------------------- $_____________ ______________ School (preschool, college, other schooling expenses)--------------------- $___________________________ Payment of child/spousalupport s from prior marriage--------------------- $___________________________ 2 FORM 9(b) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Auto expense (gas, oil, repairs)------------------------------------------------ $___________________________ Auto insurance----------------------------------------------------------------- -- $___________________________ Auto payments (EXCLUDE PAYROLL DEDUCT.)---------------------- $___________________________ Transportation (other than automobile)--------------------------------------- $___________________________ Entertainment (clubs, movies, recreation, tavelr, etc.)---------------------- $___________________________ Incidentals (groomng, gii fts, etc.)----------------------------------------------$_____________________ ______ Installment payments (charges, etc. not previously included)------------- $___________________________ Other monthly expenses (specify)_____________________------------- $___________________________ _____________________------------- $___________________________ _____________________--------------$___________________________ _____________________--------------$___________________________ _____________________--------------$___________________________ _____________________--------------$___________________________ _____________________--------------$___________________________ _____________________--------------$___________________________ TOTAL MONTHLY LIVING EXPENSES $___________________________ ASSETS REAL ESTATE : (If more than one parcel owned, please attach schedule with following information): Address:____________________________ Original Cost: $___________________________ ____________________________ Improvements: $___________________________ Type of Property:_____________________ Total Costs: $___________________________ Date of Purchase:_____________________ Liens: $___________________________ How Title Held:______________________ Present Value: $___________________________ Mortgage holder:_____________________ Taxes: $___________________________ CERTIFICATES OF DEPOSIT: Certificate Number:___________________ Ce
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