Settlement Financial Statement {04-1888A}

Settlement Financial Statement My settlement offer: $__________________ CSSD Case Number: ___________________ Full Name: _____________________________________ Date of Birth: ___________ Current Address: _________________________________ How Long? _____________ _________________________________ _________________________________ Do you rent? ___ Yes, ___ No Do you own your home? ___ Yes, ___ No If financed, with whom? ___________________________ Telephone: Home: ________________. Work: ________________________ If less than five years, provide previous 2 addresses: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Have you been incarcerated for more than one year? ___ Yes, ___ No Driver's License: Number: _________________ State Issued: ______________ Expiration Date: ___________ Current Employer: ______________________________ How long? _________ ______________________________ Gross Earnings: _________ ______________________________ If employed less than 2 years, previous 2 employers: ______________________________ How long? _________ ______________________________ ______________________________ Phone #____________ CSSD 04-1888A (Rev 12/28/09) 1 American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ How long? _________ ______________________________ ______________________________ Phone # ______________ Do you have any other source of income? ___ Yes, ___ No If yes, what is the source: ____________________ How much? _________ 1. Household members (People living with you) If there are more than 4, use the back of the form to list additional members: Name Age Relationship ________________________ ________________________ ________________________ ________________________ __________ __________ __________ __________ ______________________________ ______________________________ ______________________________ ______________________________ 2. Your Household Income: Yours a. Current Monthly Income: Wages: Social Security: Public Assistance: Unemployment: Other (specify) ____________ ________________________ Total Monthly Income: $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ Other $______________ $______________ $______________ $______________ $______________ $______________ b. Please provide the following: (1). Your last years tax return (2). Your last 2 months of pay stubs c. Permanent Fund Dividends received in last 12 months $ _________ $__________ d. ANCSA or other corporate dividends received in last 12 months $ _________ Source of dividends: _____________________________________________ ______________________________________________________________ e. Total household Income during last 12 months: $ _________ f. Do you expect to receive other income within the next 6 months (gifts, Settlements, dividends or inheritances)? ____ Yes, ____ No g. Do you have a business license? ___ Yes, ___ No Name of business if yes: ________________________ CSSD 04-1888A (Rev 12/28/09) 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. Monthly Household Expenses: Expenses Food Housing: Rent/Mortgage Utilities: Gas, Elec., Water Garbage, Telephone Transportation (gas/bus) Car Payment Through who: __________ ______________________ Insurance Child Support/Alimony List Loans & Credit Card Debts: _______________ _____________________ _____________________ _____________________ Medical (not covered by ins) Childcare Miscellaneous Expenses Cable TV Club Membership Fees Internet Fees Subscriptions (newspaper) Entertainment Alcohol/Tobacco Total Amount $_______ $ _______ $ _______ $ _______ $ _______ $ _______ Acct #_______________ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ 4. Cash and Assets: (Things you own or are buying) include all things you own by yourself and all things you own jointly with someone else. Value Cash $ __________ Balance Bank Acct./Checking Bank Acct/Savings $ __________ $ __________ Bank Name: ________________ ___________________________ Bank Name: ________________ ___________________________ 3 CSSD 04-1888A (Rev 12/28/09) American LegalNet, Inc. www.FormsWorkFlow.com Stocks, Bonds, CD's, Mutual Funds Retirement Plans $ __________ $ __________ $ __________ With Whom: _________________ ____________________________ With Whom: _________________ Items: List below, land, homes, trailers, motor vehicles, snow machines, ATVs, boats, airplanes, motorcycles. If financed, please list the financing company and the terms of the contract on a separate sheet of paper and attach to this statement. Value _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ Other: ________________ _____________________ _____________________ TOTALS: $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ (-) Amount Still Owed $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ _____________ = $ __________ Are any of the above items required to earn your living? ___ Yes, ___ No If yes, list the item and describe why you need it ___________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ CSSD 04-1888A (Rev 12/28/09) 4 American LegalNet, Inc. www.FormsWorkFlow.com 5. Credit Cards. List all your credit cards. Type of Card & Institution Through ____________ ____________ ____________ ____________ ____________ ____________ Credit Limit $ _________ $ _________ $ _________ Balance Owed $ __________ $ __________ $ _