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Financial Disclosure Form - Nevada
| Financial Disclosure Form Form. This is a Nevada form and can be used in Family District Court Clark County . |
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CODE: Nevada Bar No. Attorney For IN THE FAMILY DIVISION JUDICIAL DISTRICT COURT OF THE , STATE OF NEVADA IN AND FOR THE COUNTY OF Plaintiff or Petitioner Case No. Dept. No. Defendant or Respondent / FINANCIAL DISCLOSURE FORM Financial Statement of: First name Occupation: Employed by: Previously Employed by: Age & Date of Birth: Level of Education: Level of Disability, if Any: Marriage Date, If Applicable: Present Home Address: From: `From: To: To: Middle Last name How many adults (over 18) live with you? How much do you receive from each of them each month? I have paid my attorney a retainer of $ ; and his/her hourly rate is $ I am the _____Plaintiff/Petitioner _____ Defendant/Respondent in the above action. I swear under penalty of perjury, that the contents of this Financial Disclosure Declaration are true to the best of my knowledge as of this date. I understand that by my signature I verify the material accuracy of the contents. I also understand that any willful misstatements may be contemptuous and could result in my punishment by the Court. I understand I have a duty to supplement this form upon discovering additional assets or debts or upon changed circumstances within 10 days of discovery. I declare under penalty of perjury that the foregoing and following are true and correct. Executed on Signature ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 1 of 7 Case No. Dept. No. PERSONAL INCOME SCHEDULE IF SELF-EMPLOYED OR BUSINESS OWNER PLEASE FILL IN THE BUSINESS INCOME/EXPENSE SCHEDULE YOUR OWN INCOME AMOUNT NOTE: ATTACH COPIES OF YOUR THREE MOST RECENT PAY STUBS EMPLOYMENT INCOME (if paid weekly multiply by 52 and divide by 12, if paid every two weeks, multiply by 26 and divide by 12) 1 2 Average Monthly Paycheck Deduction Social Security 3 Average Monthly Paycheck Deduction Medicare 4 Average Monthly Paycheck Deduction Health Insurance 5 Average Monthly Paycheck Deduction Retirement Plan or 401(k) 6 Average Monthly Paycheck Deduction Savings Account 7 Average Monthly Paycheck Deduction(s) Other 8 9 10 Total Paycheck Deductions Per Month (Add lines 2-8 above) Average Net Monthly Income from Employment (Subtract line 9 from line 1) Average Gross Monthly Income from Employment (all employment income including salary $________ + bonuses $________ + overtime $________ + commissions $________ + tips $________ + other $________ = Average Monthly Paycheck Deduction Income Taxes OTHER INCOME Monthly Spousal Support/Alimony Awarded by a Court 11 12 13 14 15 16 Social Security Disability/military disability 17 Supplemental Security Income (SSI) 18 Unemployment Benefits 19 Workers Compensation Payments 20 21 22 23 Other Sources of Income (Describe: such as direct contributions from roommates or indirect payment of expenses by roommates) Total Other Income Per Month (Add lines 11-21) Rental Income (Enter the Amount of Depreciation Claimed in Computing Rental Income Here: $_______) Retirement Income Including Defined-Benefit Distributions, 401(k) Distributions, military retirement Social Security Retirement Monthly Child Support: court ordered $_______ + other/voluntary child support $_______ = Investment Income (Dividends, interest and capital gains) TOTAL INCOME PER MONTH (Add lines 10 and 22) Nevada Supreme Court Revised: October 18, 2007 Page 2 of 7 ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Case No. Dept. No. 1 2 3 4 5 PERSONAL EXPENSE SCHEDULE (NOTE: ALL EXPENSES LISTED BELOW SHOULD BE ON AN AVERAGE MONTHLY BASIS annual payments divided by 12, semiannual payments divided by 6, and quarterly payments divided by 3) Mortgage or Rent: 1st Mtg. $________ + 2nd Mtg. $________ + line of credit $________ + taxes $_________ + insurance __________ = Utilities: Gas/Oil $________ + electricity $________ + TV/cable $________ + water &________ + garbage ________ = Telephone: landline $________ + cellular $________ + Internet $________ + fax $________ + other $________ = Food, Groceries & Incidentals (not including entertainment or dining out) Transportation: monthly payment/lease $________ + gas and oil ________ + repairs and maintenance, tires $________ + insurance $________ + license/registration $________+ parking $________ + public transportation $________ + other $________ House Maintenance: housekeeping $________ + garden/lawn care $________ + snow removal $________ + repairs & maintenance $________ + other $________ Entertainment: dining out $________ + movies, shows $________ + music/videos $________ + other $________ = Dues, Memberships, Fees: Professional $________ + memberships (health club, country club) $_________ homeowners $_________ fraternal $________ + business $________ + other $________ = Health/exercise: clothing/shoes $________ + fees/passes (health clubs etc.) $________ + other $________ = Clothing: self $________ + children $________ + cleaning $________ = Vacations Pets: Food $________ + boarding $________ + healthcare $________ + grooming $________ + other $________ = Healthcare: Insurance $________ + unreimbursed; medical $________ + dental $________ + orthodontic $________ + medications $________ + counseling $________ + physical therapy $________ + chiropractic $________ + other $________ = Appearance: hair $________ + nails $________ + facials/massage $________ + cosmetics $________ + other $________ = Insurance: life $________ + disability $________ + other $________ = Books, Newspapers & Magazines Church/Charitable Accounting & Tax Preparation Support of Others: Ordered Child Support $________ + voluntary child support $________ + court-ordered spousal support $________ + eldercare $________ = Miscellaneous: Gifts $________ + storage $________ + flowers $________ + savings $________ + Lawyers fees $________ + other $________ = Education: Tuition, Books & Fees $________ + extracurricular $________ + sports $________ + music $________ + other $________ = Childcare: day care $________ + preschool $________ + other $________ = Minimum Charge Card Payments and other consumer/installment debt: credit card #1 $________ + credit card #2 $________ + credit card #3 $________ + credit card #4 $________ + other debt $________ = TOTAL MONTHLY EXPENSES (Add lines 1-23 above) TOTAL AMOUNT 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 ADKT 388 Exhibit A NRCP 16.2 Financial Disclosure Form Nevada Supreme Court Revised: October 18, 2007 Page 3 of 7 Case No. Dept. No. INCOME/EXPENSE SU
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