General Financial Disclosure Form

P a g e 1 o f 7 MISC Name: Address: Phone: Email: Second Judicial District Court Washoe County, Nevada GENERAL FINANCIAL DISCLOSURE FORM A.Personal Information: 1.What is your full name? (first, middle, last) 2.How old are you? 3.What is your date of birth? 4.What is your highest level of education? B.Employment Information:1.Are you currently employed/ self-employed? (check one) No Yes If yes, complete the table below. Attached an additional page if needed. Date of Hire Employer Name Job Title Work Schedule (days) Work Schedule (shift times) 2.Are you disabled? (check one) No Yes If yes, what is your level of disability? What agency certified you disabled? What is the nature of your disability? C.Prior Employment: If you are unemployed or have been working at your current job for less than 2years, complete the following information. Prior Employer: Date of Hire: Date of Termination: Reason for Leaving: Case No. Dept. No. In the Matter of Emancipation : , (Name) A Minor. / American LegalNet, Inc. www.FormsWorkFlow.com P a g e 2 o f 7 Monthly Personal Income Schedule A. Year-to-date Income. As of the pay period ending my gross year to date pay is . B. Determine your Gross Monthly Income. Hourly Wage 327 = 327 52 Weeks = 12 Months = Hourly Wage Number of hours worked per week Weekly Income Annual Incom Gross Monthly Income Annual Salary 12 Months = Annual Incom Gross Monthly Income C. Other Sources of Income. Source of Income Frequency Amount 12 Month Average Annuity or Trust Income Bonuses Car, Housing, or Other allowance: Commissions or Tips: Net Rental Income: Overtime Pay Pension/Retirement: Social Security Income (SSI): Social Security Disability (SSD): Spousal Support Child Support Workman222s Compensation Other: Total Average Other Income Received American LegalNet, Inc. www.FormsWorkFlow.com D. Monthly Deductions Type of Deduction Amount 1. Court Ordered Child Support ( automatically deducted frompaycheck ) 2. Federal Health Savings Plan 3. Federal Income Tax 4. Amount for you: Health Insurance For Opposing Party: For your Child(ren): 5. Life, Disability, or Other Insurance Premiums 6. Medicare 7. Retirement, Pension, IRA, or 401(k) 8. Savings 9. Social Security 10. Union Dues 11. Other: (Type of Deduction) Total Monthly Deductions (Lines 1-11) Business/Self-Employment Income & Expense Schedule A. Business Income: What is your average gross (pre-tax) monthly income/revenue from self-employment or businesses? $ B. Business Expenses: Attach an additional page if needed. Type of Business E xpense Frequency Amount 12 Month Average Advertising Car and truck used for business Commissions, wages or fees Business Entertainment/Travel Insurance Legal and professional Mortgage or Rent Pension and profit - sharing plans Repairs and maintenance Supplies Taxes and licenses (include est. tax payments) Utilities Other: Total Average Business Expenses Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Personal Expense Schedule (Monthly) A. Fill in the table with the amount of money you spend each month on the following expenses and check whether you pay the expense for you, for the other party, or for both of you. Expense Monthly Amount I Pay For Me Other Party For Both Alimony/Spousal Support Auto Insurance Car Loan/Lease Payment Cell Phone Child Support (not deducted from pay) Clothing, Shoes, Etc205 Credit Card Payments (minimum due) Dry Cleaning Electric Food (groceries & restaurants) Fuel Gas (for home) Health Insurance (not deducted from pay) HOA Home Insurance (if not included in mortgage) Home Phone Internet/Cable Lawn Care Membership Fees Mortgage/Rent/Lease Pest Control Pets Pool Service Property Taxes (if not included in mortgage) Security Sewer Student Loans Unreimbursed Medical Expense Water Other: Total Monthly Expenses Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Household Information A. Fill in the table below with the name and date of birth of each child, the person the child is living with, and whether the child is from this relationship. Attached a separate sheet if needed. Child222s Name Child222s DOB Whom is this child living with? Is this child from this relationshi Has this child been certified as special needs/disabled? 1st 2nd 3rd 4th B. Fill in the table below with the amount of money you spend each month on the following expenses for each child. Type of Expense 1 st Child 2 nd Child 3 rd Child 4 th Child Cellular Phone Child Care Clothing Education Entertainment Extracurricular & Sports Health Insurance (if not deducted from pay) Summer Camp/Programs Transportation Costs for Visitation Unreimbursed Medical Expenses Vehicle Other: Total Monthly Expenses C. Fill in the table below with the names, ages, and the amount of money contributed by all persons living in the home over the age of eighteen. If more than 4 adult household members attached a separate sheet. Name Age Person222s Relationship to You (i.e. sister, friend, cousin, etc205) Monthly Contribution Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Personal Asset and Debt Chart A. Complete this chart by listing all of your assets, the value of each, the amount owed on each, and whose name the asset or debt is under. If more than 15 assets, attach a separate sheet. Line Description of Asset and Debt Thereon Gross Value Total Amount Owed Net Value Whose Name is on the Account? You, Your Spouse/Domestic Partner or Both 1. $ - $ = $ 2. $ - $ = $ 3. $ - $ = $ 4. $ - $ = $ 5. $ - $ = $ 6. $ - $ = $ 7. $ - $ = $ 8. $ - $ = $ 9. $ - $ = $ 10. $ - $ = $ 11. $ - $ = $ 12. $ - $ = $ 13. $ - $ = $ 14. $ - $ = $ 15. $ - $ = $ Total Value of Assets (add lines 1 - 15) $ - $ = $ B. Complete this chart by listing all of your unsecured debt, the amount owed on each account, and whose name the debt is under. If more than 5 unsecured debts, attach a separate sheet. Line # Description of Credit Card or Other Unsecured Debt Total Amount owed Whose Name is on the Account? You, Your Spouse/Domestic Partner or Both 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ Total Unsecured Debt (add lines 1-6) $ Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION Attorney Information: Complete the following sentences: 1. I (have/have not) retained an attorney for this case. 2. As of the date of today, the attorney has been paid a total of $ on my behalf. 3. I have a credit with my attorney in the amount of $ . 4. I currently owe my attorney at total of $ . 5. I owe my prior attorney at total of $ . IMPORTANT: Read the following paragraphs carefully and initial each one if applicable. This document does not contain the personal information of any person as defined by NRS 603A.040. I swear or affirm under penalty of perjury that I have read and followed all instructions in completing this Financial Disclosure Form. I understand that, by my signature, I guarantee the truthfulness of the information on this Form. I also understand that if I knowingly make false statements I may be subject to punishment, including contempt of court. I have attached a copy of my 3 most recent pay stubs to this form. I have attached a copy of my most recent YTD income statement/P&L statement to this form, if self-employed. I have not attached a copy of my pay stubs to this form because I am currently unemployed. Signature Date Page 7 of 7 American LegalNet, Inc. www.FormsWorkFlow.com