Financial Disclosure

Name

Address

Phone

Attorney for

Nevada State Bar No.

Judicial District Court

Nevada

Plaintiff

Defendant

Case No.

Dept.

GENERAL FINANCIAL DISCLOSURE FORM

A. Personal Information:

What is your full name? (first, middle, last)

How old are you?

What is your date of birth?

What is your highest level of education?

B. Employment Information:

Are you currently employed/ self-employed?

No Yes

Date of Hire

Employer Name

Job Title

Work Schedule (days)

Work Schedule(shift times)

Are you disabled?

No 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 2 years, complete the following information.

Prior Employer

Date of Hire

Date of Termination

Reason for Leaving

Monthly Personal Income Schedule

A. Year-to-date Income.

As of the pay period ending

My gross year to date pay

B. Determine your Gross Monthly Income.

Hourly Wage

Number of hours worked per week

Weekly Income

Annual Income

Gross Monthly Income

Annual Income

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
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 Deduction	Amount
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:

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 Expense	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

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.

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, 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 Name	Child’s DOB	Whom is this child living with?	Is this child from this relationship?	Has this child been certified as special needs/disabled?
1^st
2^nd
3^rd
4^th

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	1st Child	2nd Child	3rd Child	4th 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.

Name	Age	Person’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.

Line
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)

CERTIFICATION

Attorney Information: Complete the following sentences:

I (have/have not) retained an attorney for this case.

As of the date of today, the attorney has been paid a total of on my behalf.

I have a credit with my attorney in the amount

I currently owe my attorney a total

I owe my prior attorney a total

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.

Signature

Date

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:

Via 1^st Class U.S. Mail, postage fully prepaid addressed as follows

Via Electronic Service, in accordance with the Master Service List, pursuant to NEFCR 9, to:

Via Facsimile and/or Email Pursuant to the Consent of Service by Electronic Means on file herein to:

Executed on the day of , 20 .