Financial Disclosure Form — Property & Finances

a. General Information

No Check this box if you do not have a job and are not self-employed. Yes If yes, complete the table below. Attached an additional page if needed. Check this box if you have a job or work for yourself, then fill in the table. Date of Hire Write the date you started working at this job. Employer Name Write the name of the company or person you work for. Job Title Write the name of your position or the kind of work you do. Work Schedule (days) Write which days of the week you usually work. Work Schedule (shift times) Write the hours you usually work, like 9am to 5pm. No Check this box if you do not have a disability. Yes Check this box if you have a disability, then answer the questions below. If yes, what is your level of disability? Write how severe your disability is, such as full or partial. What agency certified you disabled? Write the name of the agency that decided you are disabled. What is the nature of your disability? Briefly describe the type of disability you have. Prior Employer: Write the name of the company you worked for before. Fill this in if you are out of work or new to your current job. Date of Hire: Write the date you started that earlier job. Date of Termination: Write the date you stopped working at that earlier job. Reason for Leaving: Explain why you left that earlier job, like laid off or quit. As of the pay period ending Write the last day of the most recent pay period shown on your pay stub. Use the date format month/day/year. my gross year to date pay is Enter the total money you have earned so far this year before taxes. You can find this on your latest pay stub. Hourly Wage Write how much money you earn for each hour you work, before taxes. Number of hours worked per week Write the typical number of hours you work in one week. Annual Income Write your total yearly pay before taxes if you earn a set salary instead of an hourly wage. Annuity or Trust Income - Frequency Tell how often you get money from an annuity or trust, like weekly, monthly, or yearly. Annuity or Trust Income - Amount Write how much money you get each time from an annuity or trust. Annuity or Trust Income - 12 Month Average Write the average monthly amount you get from an annuity or trust over a year. Bonuses - Frequency Tell how often you receive bonuses, like once a year or every few months. Bonuses - Amount Write how much money you usually get in a bonus. Bonuses - 12 Month Average Write the average monthly amount of your bonuses spread over a year. Car, Housing, or Other allowance: - Frequency Tell how often you get money for a car, housing, or other allowance. Car, Housing, or Other allowance: - Amount Write how much money you get each time for a car, housing, or other allowance. Car, Housing, or Other allowance: - 12 Month Average Write the average monthly amount of this allowance over a year. Commissions or Tips: - Frequency Tell how often you earn commissions or tips, like weekly or monthly. Commissions or Tips: - Amount Write how much you usually earn from commissions or tips each time. Commissions or Tips: - 12 Month Average Write the average monthly amount of your commissions or tips over a year. Net Rental Income: - Frequency Tell how often you get rental income after paying expenses, usually monthly. Net Rental Income: - Amount Write how much rental money you keep each time after paying expenses. Net Rental Income: - 12 Month Average Write the average monthly rental income you keep over a year. Overtime Pay - Frequency Tell how often you earn overtime pay, like weekly or monthly. Overtime Pay - Amount Write how much extra money you earn from overtime each time. Overtime Pay - 12 Month Average Write the average monthly amount of your overtime pay over a year. Pension/Retirement: - Frequency Tell how often you get pension or retirement payments, usually monthly. Pension/Retirement: - Amount Write how much money you get each time from a pension or retirement. Pension/Retirement: - 12 Month Average Write the average monthly amount of your pension or retirement income over a year. Social Security Income (SSI): - Frequency Tell how often you get Social Security Income, usually monthly. Social Security Income (SSI): - Amount Write how much you get each time from Social Security Income. Social Security Income (SSI): - 12 Month Average Write the average monthly amount of your Social Security Income over a year. Social Security Disability (SSD): - Frequency Tell how often you get Social Security Disability payments, usually monthly. Social Security Disability (SSD): - Amount Write how much you get each time from Social Security Disability. Social Security Disability (SSD): - 12 Month Average Write the average monthly amount of your Social Security Disability income over a year. Spousal Support - Frequency Tell how often you receive spousal support payments, usually monthly. Spousal Support - Amount Write how much spousal support money you get each time. Spousal Support - 12 Month Average Write the average monthly amount of spousal support you receive over a year.

b. Child Support

Child Support - Frequency Tell how often you receive child support payments, usually monthly. Child Support - Amount Write how much child support money you get each time. Child Support - 12 Month Average Write the average monthly amount of child support you receive over a year. Workman's Compensation - Frequency Tell how often you get workman's compensation payments. Workman's Compensation - Amount Write how much workman's compensation money you get each time. Workman's Compensation - 12 Month Average Write the average monthly amount of workman's compensation over a year. Other: ____________ Name any other type of income you get that is not listed above. Other: - Frequency Tell how often you get this other income. Other: - Amount Write how much you get each time from this other income. Other: - 12 Month Average Write the average monthly amount of this other income over a year. Court Ordered Child Support (automatically deducted from paycheck) Enter the monthly amount of child support taken out of your paycheck because a court ordered it. Federal Health Savings Plan Enter how much is taken from your pay each month for a federal health savings account. Federal Income Tax Enter the amount of federal income tax taken out of your pay each month. Amount for you: Enter how much you pay each month for your own health insurance. For Opposing Party: Enter how much you pay each month to cover the other party on your health insurance. For your Child(ren): Enter how much you pay each month to cover your children on your health insurance.

c. Health & Medical Support

Life, Disability, or Other Insurance Premiums Enter the monthly cost of any life, disability, or other insurance taken from your pay. Medicare Enter the amount taken from your pay each month for Medicare. Retirement, Pension, IRA, or 401(k) Enter how much is taken from your pay each month for retirement savings like a pension, IRA, or 401(k). Savings Enter how much is taken from your pay each month and put into savings. Social Security Enter the amount taken from your pay each month for Social Security. Union Dues Enter how much you pay each month in union dues. Other: (Type of Deduction) Name any other deduction taken from your pay that is not listed above. Other: (Type of Deduction) Enter the monthly amount for the other deduction you named. What is your average gross (pre-tax) monthly income/revenue from self-employment or businesses? $ Enter your typical monthly income from self-employment or your business before taxes are taken out. Advertising Enter how often you pay for advertising, such as monthly or yearly. Advertising Enter how much you pay each time for advertising your business. Advertising Enter the average monthly cost of advertising over the past year. Car and truck used for business Enter how often you pay for the car or truck used for your business. Car and truck used for business Enter how much you pay each time for the car or truck used for business. Car and truck used for business Enter the average monthly cost for the car or truck over the past year. Commissions, wages or fees Enter how often you pay commissions, wages, or fees. Commissions, wages or fees Enter how much you pay each time in commissions, wages, or fees. Commissions, wages or fees Enter the average monthly amount for commissions, wages, or fees over the past year. Business Entertainment/Travel Enter how often you spend money on business entertainment or travel. Business Entertainment/Travel Enter how much you spend each time on business entertainment or travel. Business Entertainment/Travel Enter the average monthly cost of business entertainment or travel over the past year. Insurance Enter how often you pay for business insurance. Insurance Enter how much you pay each time for business insurance. Insurance Enter the average monthly cost of business insurance over the past year. Legal and professional Enter how often you pay for legal or professional services. Legal and professional Enter how much you pay each time for legal or professional services. Legal and professional Enter the average monthly cost of legal or professional services over the past year. Mortgage or Rent Enter how often you pay mortgage or rent for your business space. Mortgage or Rent Enter how much you pay each time for business mortgage or rent. Mortgage or Rent Enter the average monthly business mortgage or rent over the past year. Pension and profit-sharing plans Enter how often you pay into pension or profit-sharing plans for your business. Pension and profit-sharing plans Enter how much you pay each time into pension or profit-sharing plans. Pension and profit-sharing plans Enter the average monthly amount for pension or profit-sharing plans over the past year. Repairs and maintenance Enter how often you pay for business repairs and maintenance. Repairs and maintenance Enter how much you pay each time for business repairs and maintenance. Repairs and maintenance Enter the average monthly cost of repairs and maintenance over the past year. Supplies Enter how often you buy supplies for your business. Supplies Enter how much you spend each time on business supplies. Supplies Enter the average monthly cost of business supplies over the past year. Taxes and licenses (include est. tax payments) Enter how often you pay business taxes and licenses, including estimated tax payments. Taxes and licenses (include est. tax payments) Enter how much you pay each time for business taxes and licenses. Taxes and licenses (include est. tax payments) Enter the average monthly cost of business taxes and licenses over the past year. Utilities Enter how often you pay utility bills for your business. Utilities Enter how much you pay each time for business utilities. Utilities Enter the average monthly cost of business utilities over the past year. Other: Name any other business expense not already listed above. Other: Enter how often you pay this other business expense. Other: Enter how much you pay each time for this other business expense. Other: Enter the average monthly cost of this other business expense over the past year. I (have/have not) ___ retained an attorney for this case. Write 'have' if you hired a lawyer for this case, or 'have not' if you did not. As of the date of today, the attorney has been paid a total of $___ on my behalf. Enter the total dollar amount that has been paid to your attorney so far. I have a credit with my attorney in the amount of $___. Enter any money your attorney is holding for you or owes back to you. I currently owe my attorney a total of $___. Enter the dollar amount you still owe your current attorney. I owe my prior attorney a total of $___. Enter the dollar amount you still owe a lawyer you used before this one.