Financial Disclosure

GENERAL FINANCIAL DISCLOSURE FORM

A. Personal Information:

B. Employment Information:

C. Prior Employment: If you are unemployed or have been working at your current job for less than 2 years, complete the following information.

Monthly Personal Income Schedule

A. Year-to-date Income.

B. Determine your Gross Monthly Income.

C. Other Sources of Income.

Source of IncomeFrequencyAmount12 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

Workman’s Compensation

Total Average Other Income Received

Total Average Gross Monthly Income (add totals from B and C above)

C. Monthly Deductions

#Type of DeductionAmount
1.Court Ordered Child Support (automatically deducted from paycheck)

2.Federal Health Savings Plan

3.Federal Income Tax

4.

Health Insurance

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.

Total Monthly Deductions (Lines 1-11)

Business/Self-Employment Income & Expense Schedule

A. Business Income:

B. Business Expenses: Attach an additional page if needed.

Type of Business ExpenseFrequencyAmount12 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

Total Average Business Expenses

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.

ExpenseMonthly Amount I PayFor MeOther PartyFor Both
Alimony/Spousal Support

Auto Insurance

Car Loan/Lease Payment

Cell Phone

Child Support (not deducted from pay)

Clothing, Shoes, Etc…

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

Total Monthly Expenses


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.

#Child’s NameChild’s DOBWhom is this child living with?Is this child from this relationship?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 Expense1st Child2nd Child3rd Child4th 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

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.

NameAgePerson’s Relationship to You
(i.e. sister, friend, cousin, etc…)
Monthly Contribution

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.

LineDescription of Asset and Debt ThereonGross Value
Total Amount Owed
Net ValueWhose 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 DebtTotal Amount OwedWhose 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)

CERTIFICATION

Attorney Information: Complete the following sentences:

IMPORTANT: Read the following paragraphs carefully and initial each one.

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.

CERTIFICATE OF SERVICE

I hereby declare under the penalty of perjury of the State of Nevada that the following is true and correct:

That on (date) , service of the General Financial Disclosure Form was made to the following interested parties in the following manner:

Executed on the day of , 20 .