Title: In Re: Uniform Chancery Court Rules

State: mississippi

Issuer: Mississippi Supreme Court

Document:

Serial: 165478 IN THE SUPREME COURT OF MISSISSIPPI No. 89-R-99006-SCT IN RE: UNIFORM CHANCERY COURT RULES ORDER This matter is before the Court en banc on the Petition to Amend Rule 8.05 of the Uniform Chancery Court Rules filed by the Family Law Section of the Mississippi Bar. After due consideration, the Court finds that the petition should be granted to the limited extent that Rule 8.05 and Forms are amended and adopted as set forth in the exhibit to this order. All other suggested revisions are denied. IT IS THEREFORE ORDERED that the Petition to Amend Rule 8.05 of Uniform Chancery Court Rules filed by the Family Law Section of the Mississippi Bar is hereby granted, in part. Rule 8.05 is amended as set forth in the exhibit to this order. IT IS FURTHER ORDERED that the Clerk of this Court shall spread this order upon the minutes of the Court and shall forward a true certified copy hereof to West Publishing Company for publication in the next edition of the Mississippi Rules of Court and in the Southern Reporter, Third Series (Mississippi Edition). SO ORDERED, this the 28th day of October, 2010. /s/ Michael K. Randolph MICHAEL K. RANDOLPH, JUSTICE FOR THE COURT TO GRANT, IN PART: ALL JUSTICES. Exhibit RULE 8.05 FINANCIAL STATEMENT REQUIRED Unless excused by Order of the Court for good cause shown, each party in every domestic case involving economic issues and/or property division shall provide the opposite party or counsel, if known, the following disclosures: (A) A detailed written statement of actual income and expenses and assets and liabilities, such statement to be on the forms attached hereto as Exhibit “A”, copies of the preceding year’s Federal and State Income Tax returns, in full form as filed, or copies of W- 2s if the return has not yet been filed; and, a general statement of the providing party describing employment history and earnings from the inception of the marriage or from the date of divorce, whichever is applicable; or, (B) By agreement of the parties, or on motion and by order of the Court, or on the Court’s own motion, a more detailed statement on the form attached hereto as Exhibit “B”. The party providing the required written statement shall immediately file a Certificate of Compliance with the Chancery Clerk for filing in the court file. A party filing a document containing personal identifiers and/or sensitive information and data may (1) file an unredacted document under seal; this document shall be retained by the court as part of the record; or, (2) file a reference list under seal. The reference list shall contain the complete personal data identifiers and/or the complete sensitive information and data required by this Rule. The foregoing disclosures shall be made by the plaintiff not later than the time that the defendant’s Answer is due, and by the defendant at the time that the defendant’s Answer is due, but not later than 45 days from the date of the filing of the commencing pleading. The Court may extend or shorten the required time for disclosure upon written motion of one of the parties and upon good cause shown. When offered in a trial or a conference, the party offering the disclosure statement shall provide a copy of the disclosure statement to the Court, the witness and opposing counsel. This rule shall not preclude any litigant from exercising the right of discovery, but duplicate effort shall be avoided. The failure to observe this rule, without just cause, shall constitute contempt of Court for which the Court shall impose appropriate sanctions and penalties. [Amended effective July 1, 1996; amended effective January 8, 2009, to provide procedures for filing documents containing sensitive personal information: amended effective July 1, 2011 to incorporate an optional long form financial statement.] EXHIBIT “A” IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NUMBER DEFENDANT vvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvvv I. GENERAL INFORMATION NAME: _______________________________________________________________ ADDRESS: ___________________________________________________________ CITY, STATE AND ZIP CODE: __________________________________________ DATE OF BIRTH: ______________________________________________________ SOCIAL SECURITY NUMBER: __________________________________________ OCCUPATION: ________________________________________________________ EMPLOYER: __________________________________________________________ EMPLOYER’S ADDRESS: ______________________________________________ ______________________________________________________________________ NAME DATE OF BIRTH MINOR CHILDREN: II. INCOME STATEMENT GROSS MONTHLY INCOME 1. Salary and Wages, including commissions bonuses, allowance and overtime 1. ____________________ NOTE: To arrive at a monthly income figure, if paid weekly, multiply weekly income by 4.3; if paid bi-weekly, multiply bi-weekly income by 2.16 2. Pensions and retirement 2. ____________________ 3. Social Security 3. ____________________ 4. Disability and unemployment insurance 4. ____________________ 5. Public assistance (welfare, AFDC payments, etc.) 5. ____________________ 6. Dividends and interest 6. ____________________ 7. Rental Income 7. ____________________ 8. Other income 8. ____________________ 9. Other income 9. ____________________ 10. TOTAL MONTHLY INCOME 10. ____________________ ITEMIZED MONTHLY DEDUCTIONS: 1. State Income Taxes 1. ____________________ 2. Federal Income Taxes 2. ____________________ 3. Social Security 3. ____________________ 4. Mandatory Insurance 4. ____________________ 5. Mandatory Retirement 5. ____________________ 6. Union or other dues 6. ____________________ 7. Other: (Specify) 7. ____________________ 8. Other: (Specify) 8. ____________________ 9. TOTAL MONTHLY DEDUCTIONS 9. ____________________ 10. NUMBER OF EXEMPTIONS: 11. NET MONTHLY PAY 11. ____________________ III. EXPENSE STATEMENT A. LIVING EXPENSES AS OF AS OF Self Children Self Children 1. Rent/Mortgage (Residence) 2. Real Property Taxes 3. Real Property Insurance 4. Maintenance (Residence) 5. Food/Household Supplies 6. Water, Sewer, etc. 7. Electricity 8. Gas (Residence) 9. Telephone 10. Laundry & Cleaning 11. Clothing 12. Insurance (Not payroll deducted) 13. Medical 14. Dental 15. Child Care 16. Children’s Allowance 17. Payment of child support/alimony (Prior Marriage) 18. School Expenses 19. Entertainment 20. Incidentals & Miscellaneous 21. Transportation other than vehicle 22. Gasoline & Oil (auto) 23. Repair (auto) 24. Insurance (auto) 25. Auto payments 26. Church donations III. EXPENSE STATEMENT Self Children Self Children 27. Charitable donations 28. Newspaper/Magazines 29. Cable TV 30. Pet Expenses 31. Yard Expenses 32. Maid 33. Retirement (IRA, etc.) 34. Pest Control B. TOTAL LIVING EXPENSES 35. Installment Payments Notes, loans, charge accounts, etc. 36. 37. 38. 39. OTHER EXPENSES 40. 41. TOTAL INSTALLMENT PAYMENTS: COMBINED TOTAL EXPENSES: IV. STATEMENT OF ASSETS A. Real Estate 1. Title in the name of : _____________________________________________ Address: _____________________________________________ Who paid cost: _____________________________________________ How cost paid: _____________________________________________ Value (estimate) _____________________________________________ Mortgage Balance ____________________________________________ Equity _____________________________________________ 2. Title in the name of : _____________________________________________ Address: _____________________________________________ Who paid cost: _____________________________________________ How cost paid: _____________________________________________ Value (estimate) _____________________________________________ Mortgage Balance ____________________________________________ Equity _____________________________________________ Note: List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under “V. LIABILITIES.” B. Motor Vehicles 1. Registered in the name of: __________________________________________ Year: Model: Mileage: How cost paid: How cost paid: VALUE - Loan Balance ____________________________________________ =Equity _____________________________________________ 2. Registered in the name of: __________________________________________ Year: Model: Mileage: How cost paid: How cost paid: VALUE - Loan Balance ____________________________________________ =Equity _____________________________________________ IV. STATEMENT OF ASSETS (Continued) 3. Registered in the name of: __________________________________________ Year: Model: Mileage: How cost paid: How cost paid: VALUE - Loan Balance ____________________________________________ =Equity _____________________________________________ C. Other Personal Property (such as home computers, guns, lawnmowers, TVs, jewelry, household furnishings, etc.) VALUES TOTAL D. Checking/Savings (name of Bank, Account Number and Amount in Account, including CDs, money markets, passbook accounts, etc. Name(s) on Account Bank/Account Number Type Account Balance TOTAL VALUE E. Other Investments (IRAs, stock(s), mutual funds, pension plans, etc.) Bank/Account Number Type Investment Balance F. Life Insurance (exclude children) Insured Company Face Amount Cash Beneficiary TOTAL CASH VALUE (less loans) G. All Other Assets TOTAL VALUE TOTAL OF ALL ASSETS $ V. STATEMENT OF LIABILITIES (Include mortgage, car loan, credit cards, personal loans) Note: Also include under items 35-44 on Exhibit “A” A. Creditor Party Responsible Current Monthly Who Makes for Payment Balance Payment Payments 1. 2. 3. 4. 5. 6. B. TOTAL LIABILITIES ACKNOWLEDGMENT OF TRUTHFULNESS I declare to the Court that the foregoing Exhibit “A” including attachments, is true and correct and that this declaration was executed on the ______ day of ____________, 20___, Party’s Signature IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI PLAINTIFF CIVIL ACTION NUMBER DEFENDANT CERTIFICATE OF COMPLIANCE I, (name of party or attorney) , do hereby certify that I have this date complied with Rule 8.05 of the Uniform Chancery Court Rules and that I have mailed and/or delivered a copy of a detailed written statement of actual income and expenses and assets and liabilities to the attorney for the opposing party or the opposing party. SO CERTIFIED on this the _____ day of _______________, 20____. Attorney Or Opposing Party EXHIBIT “B” IN THE CHANCERY COURT OF ___________________ COUNTY, MISSISSIPPI _______________ JUDICIAL DISTRICT ______________________________ PLAINTIFF VS CAUSE NO. _______________ ______________________________ DEFENDANT RULE 8.05 FINANCIAL STATEMENT I, (full legal name) ________________________________,certify that the following information is true: SECTION I. GENERAL INFORMATION 1. Date of Birth: _____________________ 2 Physical Address: ___________________________________________________________________ 3. Mailing Address: _____________________________________________________________________ 4. A. Minor Children (below the age of 21) or a full-time student above the age of 21: Name Date of Birth Child Support Order in effect? (Yes or No) Amount of Monthly Child Support Order Payment B. Adult Children being supported by you Name Date of Birth Child Support Order in effect? (Yes or No) Amount of Monthly Child Support Order Payment 5. Are you subject to and/or a party in any litigation or other court proceedings? (Bankruptcy, Class Action, Worker’s Compensation, Personal Injury, etc.) If yes, please provide the style of the action including cause number and a brief description of the nature thereof. ______________________________________________________________________ _______________________________________________________________________ 1. My occupation is:_________________________________________________________ 2. I am currently: [T all that apply] ____ a. Unemployed 1. Describe your efforts to find employment, how soon you expect to be employed, and the pay you expect to receive:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 2. Provide a statement of your employment history and earnings from the inception of the marriage, or from the date of divorce, (whichever is applicable) on a separate sheet paper and attach it to this form. Label the attachment “Employment History”. ____ b. Employed by:______________________________________________________ 1. Address:______________________________________________________________ 2. City, State, Zip Code:___________________________________________________ 3. Telephone Number:____________________________________________________ 4. My position is:__________________________________________________________ 5. Pay rate: $___________ ( ) every week ( ) every other week ( ) twice a month ( ) monthly ____ Check here if you currently have more than one job. List the information above for the second job(s) on a separate sheet and attach it to this statement. ____ Check here if you are self-employed, own an interest in a business or farm, receive income from rental property, or if you report income or expenses on Schedule C, Schedule E, or Schedule F of your tax return. SECTION II. INCOME Complete Exhibit 1 attached hereto. ____ Check here if you are expecting to become unemployed or change jobs soon, describe the change you expect and why and how it will affect your income: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ____ c.Retired. Date of retirement: ____________________________________________ 1. Employer from whom retired: _____________________________________________ 2. Address: ____________________________________________________________ 3. City, State, Zip Code: ______________________ Telephone Number: ____________ 4. Are you receiving retirement pay or benefits from this employer? _____ yes _____ no _____ d. Is there any information which you think would be helpful for the Court to know about your employment? (If so, give comments here). __________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ LAST YEAR’S GROSS INCOME FROM TAX RETURN: Your Income Other Party’s Income (if known) Year ________ $____________ $_________________ LAST YEAR’S ADJUSTED GROSS INCOME FROM TAX RETURN: Your Income Other Party’s Income (if known) Year ________ $____________ $_________________ LAST YEAR’S TAX REFUND FROM TAX RETURN: Federal Refund State Refund Year _________ $_____________ $_________________ OUTSTANDING TAX LIABILITIES FROM TAX RETURN: Federal State Year _________ $______________ $_________________ Does the IRS or the State of Mississippi currently have a tax lien on any items of property?_______ If yes, please state the total amount of the tax lien and the items encumbered. ____________________________________________________________________________ ____________________________________________________________________________ PRESENT MONTHLY GROSS INCOME: All amounts must be MONTHLY. Attach more paper, if needed. Items included under “other” should be listed separately with separate dollar amounts. 1. Monthly gross salary or wages 1.$___________________ 2. Bonuses, commissions, allowances, overtime, tips, and similar payments 2. ____________________ 3. Average monthly business income for previous 6 months from sources such as self-employment, partnerships, close corporations, and/or independent contracts (Gross receipts minus ordinary and necessary expenses required to produce income.) (! Attach sheet itemizing such income and expenses) 3.____________________ 4. Monthly disability benefits 4. ____________________ 5. Monthly Workers’ Compensation 5.____________________ 6. Monthly Unemployment Compensation 6.____________________ 7. Monthly pension, retirement, or annuity payments 7.____________________ 8. Monthly Social Security benefits 8.____________________ 9. Monthly alimony actually received 9a. From this case: $_________ 9b. From other case(s) __________ Add 9a and 9b 9.____________________ 10. Monthly interest and dividends 10.___________________ 11. Monthly rental income (gross receipts minus ordinary and necessary expenses required to produce income) (!Attach sheet itemizing each item and amount) 11.___________________ 12. Monthly income from royalties, trusts, and estates 12.___________________ If you are paid on a schedule which is not monthly, you must convert those amounts. Conversion are as follows: 1. Paid Weekly, multiply by 4.33 2. Paid bi-weekly, multiply by 2.16 3. Paid on the 1 and 15 , or on 15 and 30th/31st, multiply by 2 st th th 4. Paid annually divide by 12 13. Monthly reimbursed expenses and in-kind payments to the extent that they reduce personal living expenses such as cars, travel, gas, phone, etc. (!Attach sheet itemizing each item and amount) 13.___________________ 14. Monthly income from property such as CRP payments or subsidies 14.___________________ 15. Public Assistance (Welfare, AFDC Payments, CHIPS, Etc.) 15.___________________ 16. Severance Pay 16.___________________ 17. Monthly Investment Income 17.___________________ 18. Other:________________________________________________ 18.___________________ 19. Other:________________________________________________ 19.___________________ 20. Other:________________________________________________ 20.___________________ 21. PRESENT MONTHLY GROSS INCOME (Add lines 1-20) TOTAL: 21. ___________________ PRESENT MONTHLY DEDUCTIONS: All amounts must be MONTHLY. 22. Present Monthly Federal Income Tax. a. Anticipated Filing Status for the Present Year:____________ (e.g. single, head of household, married filing separate, etc) b. Filing Status Last Year:______________________________ c. Anticipated Number of Dependents claimed for Present Year:___ d. Number of Dependents claimed Last Year: ____________ e. Number of Exemptions claimed for the Present Year:__________ f. Number of Exemptions claimed Last Year: ____________ 22._________________ 23. Present Monthly State Income Tax a. Anticipated Filing Status for the Present Year:______________ (e.g. single, head of household, married filing separate, etc.) b. Filing Status Last Year:_______________________________ c. Anticipated Number of Dependents claimed for Present Year:____ d. Number of Dependents claimed Last Year: ____________ e. Number of Exemptions claimed for the Present Year:__________ f. Number of Exemptions claimed Last Year: ____________ 23._________________ 24. Monthly FICA or self-employment taxes 24.__________________ 25. Monthly Medicare payment 25.__________________ 26. Monthly mandatory union dues 26.__________________ 27. Monthly mandatory retirement payments 27.__________________ 28. Monthly court-ordered child support actually paid for children from another relationship 28.__________________ 29. Monthly court-ordered alimony actually paid 28a. From this case: $________________ 28b. From other case(s): _________________ Add 28a and 28b 29.__________________ 30. Other Mandatory Monthly Deductions. 30.__________________ 31. TOTAL MONTHLY DEDUCTIONS: (Add lines 22 through 29) 31.__________________ 32. PRESENT NET MONTHLY INCOME (Total Gross Income minus Total Monthly Deductions) 32.__________________ If you have deductions which are not deducted on a monthly basis, you must convert those amounts. Conversion are as follows: 1. Paid Weekly, multiply by 4.33 2. Paid bi-weekly, multiply by 2.16 3. Paid on the 1 and 15 , or on 15 and 30th/31st, multiply by 2 st th th SECTION III. MONTHLY EXPENSES All amounts must be MONTHLY. A. HOUSEHOLD: PRE-SEPARATION CURRENT: PROPOSED/ ESTIMATE EXPENSES: 1. Monthly mortgage or rent payments 1. ______________ 1. ____________ 1. ________________ 2. Monthly property taxes (if not included in mortgage) 2. ______________ 2. ____________ 2. ________________ 3. Monthly insurance on residence (if not included in mortgage) 3. ______________ 3. ____________ 3. _________________ 4. Monthly homeowners’ association fees 4. ______________ 4. ____________ 4. _________________ 5 Monthly electricity 5. ______________ 5. ____________ 5. _________________ 6. Monthly water, garbage, and sewer 6._______________ 6. ____________ 6. _________________ 7. Monthly telephone a. Land line b. Cell phone 7. ______________ 7. ____________ 7. _________________ 8. Monthly residence gas 8. ______________ 8. ____________ 8. _________________ 9. Monthly repairs and maintenance 9. ______________ 9. ____________ 9. _________________ 10. Monthly lawn care 10. _____________ 10. ___________ 10. ________________ 11. Monthly pest control 11. _____________ 11. ___________ 11. ________________ 12. Monthly misc. household supplies 12. _____________ 12. ___________ 12. ________________ 13. Monthly food 13. _____________ 13. ___________ 13. ________________ 14. Monthly meals outside home 14. _____________ 14. ___________ 14. ________________ 15. Monthly cable t.v. 15. _____________ 15. ___________ 15. ________________ 16. Monthly internet service 16. _____________ 16. ___________ 16. ________________ 17. Monthly alarm service contract 17. _____________ 17. ___________ 17. ________________ 18. Monthly service contracts on appliances 18. _____________ 18. ___________ 18. ________________ 19. Monthly maid service 19. _____________ 19. ___________ 19. ________________ 20. Monthly dry cleaning and laundry 20. _____________ 20. ___________ 20. ________________ 21. Monthly clothing 21. _____________ 21. ___________ 21. ________________ 22. Monthly medical, dental, and prescription (only those not covered by insurance or otherwise reimbursed) 22. _____________ 22. ___________ 22. ________________ For any expenses which are not paid monthly, you must convert those amounts. Conversion are as follows: 1. Paid Weekly, multiply by 4.33 2. Paid bi-weekly, multiply by 2.16 3. Paid on the 1 and 15 , or on 15 and 30th/31st, multiply by 2 st th th 4. Paid annually divide by 12 23. Monthly psychiatric, psychological, or counselor (only those not covered by insurance or otherwise reimbursed) 23. _____________ 23. ___________ 23. __________________ 24. Monthly nonprescription medications, cosmetics, toiletries, and sundries 24. _____________ 24. __________ 24. _________________ 25. Monthly grooming 25. _____________ 25. ___________ 25. __________________ 26. Monthly gifts 26. _____________ 26. ___________ 26. __________________ 27. Monthly pet expenses 27. _____________ 27. ___________ 27. __________________ 28. Monthly club dues and membership 28. _____________ 28. ___________ 28. __________________ 29. Monthly sports and hobbies 29. _____________ 29. ___________ 29. __________________ 30. Monthly entertainment 30. _____________ 30. ___________ 30. __________________ 31. Monthly tolls and parking 31. _____________ 31. ___________ 31. __________________ 32. Monthly periodicals/newspapers/ magazines/books/tapes/CDs 32. _____________ 32. ___________ 32. __________________ 33. Monthly vacations 33. _____________ 33. ___________ 33. __________________ 34. Monthly education expenses 34. _____________ 34. ___________ 34. __________________ 35. SUBTOTAL 35. _____________ 35. ___________ 35. __________________ B. VEHICLES AND BOATS 36. Monthly gasoline and oil 36. _____________ 36. ___________ 36. __________________ 37. Monthly repairs 37. _____________ 37. ___________ 37. __________________ 38. Monthly tags 38. _____________ 38. ___________ 38. __________________ 39. Monthly insurance for each vehicle 39.______________ 39. ___________ 39. __________________ a. _________________________ b. _________________________ c. _________________________ 40. Monthly payments (lease or financing) 40. _____________ 40. ___________ 40. __________________ 41. Monthly alternative transportation (bus, rail, car pool, etc.) 41. _____________ 41. ___________ 41. __________________ 42. Monthly tolls and parking 42. _____________ 42. ___________ 42. __________________ 43. Other: ____________________________ 43. _____________ 43. ___________ 43. __________________ 44. SUBTOTAL 44. _____________ 44. ___________ 44. __________________ C. MONTHLY EXPENSES FOR CHILDREN (In addition to the amount please indicate with “M” or “F” if the expense is normally paid by Mother or Father.) 45. Monthly nursery, babysitting, or day care 45. _____________ 45. __________ 45. __________________ 46. Monthly school tuition 46. _____________ 46. ___________ 46. __________________ 47. Monthly school supplies, books, fees and field trips 47. _____________ 47. ___________ 47. __________________ 48. Monthly after school activities (School sponsored: Math, Drama, etc.) 48. _____________ 48. ___________ 48. __________________ 49. Monthly lunch money 49. _____________ 49. ___________ 49. __________________ 50. Monthly private lessons or tutoring (music, dance, tennis, etc.) 50. _____________ 50. ___________ 50. __________________ 51. Monthly allowances (spending money, gas money, etc.) 51. _____________ 51. ___________ 51. __________________ 52. Monthly clothing and uniforms 52. _____________ 52. ___________ 52. __________________ 53. Monthly entertainment (movies, parties, etc.) 53. _____________ 53. ___________ 53. __________________ 54. Monthly medical dental, prescriptions (nonreimbursed only) 54. _____________ 54. ___________ 54. __________________ 55. Monthly psychiatric/psychological/counselor 55. _____________ 55. ___________ 55. __________________ 56. Monthly orthodontic 56. _____________ 56. ___________ 56. __________________ 57. Monthly beauty parlor/barber shop 57. _____________ 57. ___________ 57. __________________ 58. Monthly nonprescription medication 58. _____________ 58. ___________ 58. __________________ 59. Monthly cosmetics, toiletries, and sundries 59. _____________ 59. ___________ 59. __________________ 60. Monthly gifts from child(ren) to others (other children, relatives, teachers, etc.) 60. _____________ 60. ___________ 60. __________________ 61. Monthly cost of annual gifts to children (Christmas, Birthday, etc.) 61. _____________ 61. ___________ 61. __________________ 62. Monthly camp or summer activities 62. _____________ 62. ___________ 62. __________________ 63. Monthly clubs (4-H, Girl Scouts/Boy Scouts, etc.) 63. _____________ 63. ___________ 63. __________________ 64. Monthly travel expenses for visitation with minor children 64. _____________ 64. ___________ 64. __________________ 65 Other:______________________ 65. _____________ 65. ___________ 65. __________________ 66. Other:______________________ 66. _____________ 66. ___________ 66. __________________ 67. SUBTOTAL 67. _____________ 67. ___________ 67. __________________ D. MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP: (other than court-ordered child support) 68. ______________________________ 68. _____________ 68. ___________ 68. __________________ 69. ______________________________ 69. _____________ 69. ___________ 69. __________________ 70. ______________________________ 70. _____________ 70. ___________ 70. __________________ 71. SUBTOTAL 71. _____________ 71. ___________ 71. __________________ E. MONTHLY INSURANCE: 72. Health/ Medical Insurance a. Insured Premium $___________ b. Insured plus spouse Premium $______ c. Family Premium $ __________ 72. _____________ 72. ___________ 72. __________________ 73. Monthly Life Insurance Premiums 73. _____________ 73. ___________ 73. __________________ 74. Dental Insurance a. Insured Premium $__________ b. Insured plus Spouse Premium $_____ c. Family Premium $__________ 74. _____________ 74. ___________ 74. __________________ 75. Disability Insurance Premiums 75. _____________ 75. ___________ 75. __________________ 76. Optical Insurance Premiums 76. _____________ 76. ___________ 76. __________________ 77. Other:_________________________ 77. _____________ 77. ___________ 77. __________________ 78. SUBTOTAL 78. _____________ 78. ___________ 78. __________________ F. OTHER MONTHLY EXPENSES NOT LISTED ABOVE: 79. Other:______________________ 79. _____________ 79. ___________ 79. __________________ 80. Other:_________________________ 80. _____________ 80. ___________ 80. __________________ 81. Other:_________________________ 81. _____________ 81. ___________ 81. __________________ 82. Other:_________________________ 82. _____________ 82. ___________ 82. __________________ 83. SUBTOTAL 83. _____________ 83. ___________ 83. __________________ 84. TOTAL MONTHLY EXPENSES: (Add all expense Subtotals plus the monthly payments due on any liabilities that are listed in Section V., A. Liabilities, that you have not listed in 1-84) 84. _____________ 84. ___________ 84 . SUMMARY: 85. TOTAL PRESENT MONTHLY NET INCOME (from line 32 of SECTION I. INCOME) 85. $____________ 85. $__________ 85. $_________________ 86. TOTAL MONTHLY EXPENSES (from line 84 above) 86. $____________ 86. $__________ 86. $_________________ 87. SURPLUS (If line 85 is more than line 86, subtract line 86 from line 85. This is the amount of your surplus. Enter that amount here.) 87. $____________ 87. $__________ 87. $_________________ 88. (DEFICIT) (If line 86 is more than line 85, subtract line 85 from line 86. This is the amount of your deficit. Enter that amount here). 88.($___________) 88.($_________) 88.($_________________ A. REAL ESTATE The value of the real estate may be an estimate or a recent appraisal. If values are acquired from an appraisal, attach to this 8.05 Financial Statement Affidavit a copy of the appraisal. Attach additional sheets if necessary. 1. Address/Description: Primary Use (Example: primary residence, rental property, etc.): Date Acquired: Original Cost: $ County Assessed Value (County Tax Appraisal): $___________________________________ Current Fair Market Value: $ Appraisal _____ yes _____ no Appraisal Attached? _____ yes _____ no Estimate: _____ yes _____ no Mortgage Balance: $ Equity (Fair Market Value minus Mortgage Balance) $ Titled in the Name of: __________________________________________________________ Comments: __________________________________________________________________ ____________________________________________________________________________ 2. Address/Description: Primary Use (Example: primary residence, rental property, etc.): Date Acquired: Original Cost:$ County Assessed Value (County Tax Appraisal) $___________________________________ Current Fair Market Value: $ _______ Appraisal _____ yes _____ no Appraisal Attached? _____ yes _____ no Estimate: _____ yes _____ no Mortgage Balance: $ _______ Equity (Fair Market Value minus Mortgage Balance) $ Titled in the Name of: __________________________________________________________ Comments: __________________________________________________________ ____________________________________________________________________________ SECTION IV. ASSETS 3. Address/Description: Primary Use (Example: primary residence, rental property, etc.): Date Acquired: Original Cost: $ County Assessed Value (County Tax Appraisal) $___________________________________ Current Fair Market Value: $ _______ Appraisal _____ yes _____ no Appraisal Attached? _____ yes _____ no Estimate: _____ yes _____ no Mortgage Balance: $ Equity (Fair Market Value minus Mortgage Balance) $ Titled in the Name of: __________________________________________________________ Comments: __________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ TOTAL EQUITY:_____________________ B. MODULAR/ MOBILE HOMES. 1. Where is the Modular/ Mobile Home located? Primary Use (Example: primary residence, rental property, etc.): Registered in the name of: Year: Model: Value: $ Loan Balance: $ Equity: $ Comments: __________________________________________________________________ ____________________________________________________________________________ C. MOTOR VEHICLES (Cars, Trucks, RV’s, Boats, Tractors, 4-Wheelers, Motorcycles, etc.) The appropriate value for motor vehicles is the NADA value or a value from a similar source such as Kelly’s Blue Book (www.kbb.com) or Edmond’s Blue Book (www.edmonds.com). If values are acquired from these or similar sources, attach to this 8.05 Financial Statement Affidavit a copy of the printout of the assessment. Attach additional sheets if necessary. 1. Registered in the name of: Year: Model: Mileage: ______________________ How Cost Paid: Value: $ Loan Balance: $ Equity: $ Printout Attached? ______ Yes ______ No 2. Registered in the name of: Year: Model: Mileage: ____________________________ How Cost Paid: Value: $ Loan Balance: $ Equity: $ Printout Attached? ______ Yes ______ No 3. Registered in the name of: Year: Model: Mileage: ____________________________ How Cost Paid: Value: $ Loan Balance: $ Equity: $ Printout Attached? ______ Yes ______ No 4. Registered in the name of: Year: Model: Mileage: ____________________________ How Cost Paid: Value: $ Loan Balance: $ Equity: $ Printout Attached? ______ Yes ______ No TOTAL EQUITY: _______________________ D. OTHER PERSONAL PROPERTY The value of personal property should be the fair market value. Fair market value is the price at which the item could be sold to a willing buyer, under no compulsion to buy. When valuing an item consider the present condition (wear and tear, etc.) Examples of fair market value may be obtained from flea markets, garage sales, pawn shops, etc. Fair market value is not the replacement value or purchase price. Attach additional sheets if necessary. ITEM VALUE Furniture and Household Furnishings Tools Collectibles (art, coins, dolls, cars, etc.) Crystal, Silver, China, Gold Jewelry Sporting Equipment (guns, skis, golf clubs, etc.) Entertainment Equipment (televisions, stereo, pool table, etc.) Electronics (computers, digital cameras, printers, etc.) Lawn equipment Musical Instruments Other: Other: TOTAL VALUE $ E. FINANCIAL ACCOUNTS: List all checking accounts, savings accounts, money market accounts, passbook accounts, credit union accounts, etc. in which you have an interest. NAME(S) ON ACCOUNT FINANCIAL INSTITUTION OR BANK NAME TYPE OF ACCOUNT LAST FOUR(4) DIGITS ON THE ACCOUNT BALANCE 90 DAYS PRIOR TO DATE OF COMPLAINT FILED CURRENT BALANCE AS OF ___/___/__ TOTAL CHECKING/ SAVINGS $ F. OTHER INVESTMENTS List all IRAs, stocks, CD’s, mutual funds, pension plans, bonds, 401(k), PERS, Deferred Compensation, etc. NAME(S) ON INVESTMENT NAME OF FINANCIAL INSTITUTION, BROKERAGE FIRM, ETC. TYPE OF INVESTMENT LAST FOUR (4) DIGITS ON THE ACCOUNT BALANCE 90 DAYS PRIOR TO DATE OF COMPLAINT FILED CURRENT BALANCE AS OF ___/___/__ TOTAL OTHER INVESTMENTS $ G. CASH/CASH EQUIVALENTS AND OTHER ITEMS OF VALUE AMOUNT Money in your possession (on hand) Money in banks, deposit boxes, etc. not listed above Money in personal or business safes, lock boxes, etc. Money being held for you by a third person or entity Other Cash: Other Cash: TOTAL CASH $ H. LIFE INSURANCE PERSON INSURED OWNER OF POLICY COMPANY COVERAGE AMOUNT LOANS CASH VALUE LAST FOUR (4) DIGITS OF POLICY BENEFICIARY TOTAL CASH VALUE $ I. FUTURE ASSETS If you have the right to receive assets or income in the future, such as accrued vacation, sick leave, bonus, income from a trust(s), etc. you must list them here. FUTURE ASSETS Possible Value TOTAL FUTURE ASSETS $______________ J. ALL OTHER ASSETS (You are required to list all assets of value in which you have an interest, that you have not listed elsewhere on this form) DESCRIPTION OF ASSET VALUE Notes (Money owed to you in writing) Loans (Money owed to you not evidenced by a writing) Business Interest Patents, Copyrights, etc. Oil and Gas Interests Country Club and other Membership Interests (Hunting Clubs, etc.) Timber Rights Gold, Precious Metals Other: Other: TOTAL OTHER ASSETS $ SUMMARY TOTAL ASSETS: $__________________________ (ADD Total from previous Sections A through J). A. LIABILITIES List all creditors including creditors of your spouse. Include all mortgage(s), car loans, credit cards, personal loans, medical providers, credit union loans, judgments, charge accounts, etc. CREDITOR LAST FOUR (4) DIGITS OF ACCOUNT PURPOSE/ REASON FOR DEBT WHOSE NAME IS LISTED ON THE DEBT CURRENT BALANCE DUE MONTHLY PAYMENT DUE WHO PAYS 1 2 3 4 5 6 7 8 9 SECTION V. LIABILITIES Exhibit "C" - Page 18 of 1 TOTAL LIABILITIES $ $ B. CONTINGENT LIABILITIES If you have any future liabilities such as tax payments, judgments, pending lawsuits, etc. you must list them here. DESCRIPTION OF CONTINGENT LIABILITIES Contingent Amount Owed TOTAL CONTINGENT LIABILITIES $ ________ SUMMARY TOTAL LIABILITIES: $__________________________ (ADD Total from previous Sections A through B). Please list any assets including real estate, modular/mobile homes, motor vehicles, personal property, financial accounts, other investments, cash/cash equivalents and other items of value, life insurance, future assets and all other assets which you believe are separate property and should not be divided or equitably distributed in a divorce proceeding and explain your reasons in the comments section. Separate Asset Comments: Please list any liabilities including credit cards, judgments, tax liabilities, etc which you believe should not be divided or equitably distributed in a divorce proceeding and explain your reasons in the comments section. SECTION VI. SEPARATE PROPERTY and SEPARATE LIABILITIES Separate Liability Comments: ACKNOWLEDGMENT OF TRUTHFULNESS I declare to the Court that the foregoing Exhibit “B” including attachments, is true and correct and that this declaration was executed on the ______ day of ____________, 20___, Party’s Signature CERTIFICATE OF COMPLIANCE I, ____________________, do hereby certify that I have this date complied with Rule 8.05 of the Uniform Chancery Court Rules, and that I have mailed and/or delivered a copy of a detailed written statement of actual income and expenses and assets and liabilities to the attorney for the opposing party or the opposing party. SO CERTIFIED, this day of ________________, 20___. Exhibit 1 If you are self-employed, own an interest in a business or farm, receive income from rental property, or report income or expenses on Schedule C, Schedule E, or Schedule F of your tax return, please complete the following. Use additional pages if necessary. 1. Please describe the business activity:______________________________________ 2. Do you actively work in the business? YES or NO (circle appropriate response). If yes, please indicate the average number of hours worked per week:_____hours. 3. Does the business provide a vehicle for your personal use? YES or NO (circle appropriate response). If yes, please provide a description of the vehicle: ______ ______________________________________________________________________ 4. Does the business provide a vehicle for the use of any members of your immediate family? YES or NO (circle appropriate response). If yes, please provide a description of each vehicle and indicate the family member that drives the vehicle:_______________________________________________________________ 5. Do any members of your immediate family work in the business? YES or NO (circle appropriate response). If yes, please list each family member, the duties of their position, number of hours worked per week, and the rate of pay. Name Duties/ Job Description Hours Worked Per Week Pay Per Week 6. Does the business pay any expenses on your behalf or on behalf of your immediate family? YES or NO (circle the appropriate response). If yes, please describe each expense and provide the cost of the expense. (Examples: Credit Cards, Utilities, Auto Repairs, Fuel, Insurance, Cell Phone, School Tuition, Oil Changes, Medical Expenses, Pet Expenses, Meals, etc.) Description of the Expense Amount of Expense Paid by the Business 7. Does the business provide you with anything of value or a tax benefit or any “perks”? YES or NO (circle appropriate response). If yes, please describe each item of value, each tax benefit and every “perk” and provide the cost or monetary value of the same. (Examples: Hunting Leases, Country Club (dues, stock or expenses), Sporting Event Tickets, Vacations, etc.) Description of item of value, tax benefit or “perk” Cost or Monetary Value 8. Does the business own any assets that are not necessary for its operation? YES or NO (circle appropriate response) If yes, please describe the asset. (Example: Land or Art held for investment, boats, condominiums, vehicles, etc.) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 8.05 FINANCIAL DECLARATION DOCUMENT PRODUCTION REQUEST You, ________________________(name of party) must produce to __________________________ (name of opposing party or his/her attorney) within 30 days, the documents checked below if you have them in your possession or control, or if you can secure copies upon reasonable request. _____ 1. Copies of your past three (3) year’s Federal and State Income Tax returns, in full form as filed. _____ 2. A copy of your most recent Social Security Earnings Statement or a completed Form SSA-7050-F4. _____ 3. Your most recent pay check stub. _____ 4. Your most recent W-2's. _____ 5. All 1099's received by you in the past year. _____ 6. All K-1's received by you in the past year. _____ 7. Copies of the past three (3) year’s Federal and State Tax Income Tax returns, in full form as filed, for any partnership, limited liability company, corporation or limited partnership in which you own or have an interest _____ 8. Copies of your checking and saving account statements for the past twelve (12) months. _____ 9. Copies of your investment and brokerage account statements for the past twelve (12) months. _____ 10. Copies of your Certificates of Deposit, Bonds, or Stock. _____ 11. Copies of your IRA, 401(K), SEP, PERS, Pension, Deferred Compensation and any other retirement account for the past twelve (12) months. _____ 12. Copies of the declaration sheet for all life insurance policies owned by you or on which you have been a beneficiary for the past twelve (12) months. _____ 13. Copies of all credit card statements on which you have made charges for the past six (6) months. _____ 14. Copies of all loans, mortgages, promissory notes, or other documents showing debts owned by you, or debts owed to you by others. _____ 15. Copies of all deeds to real property. _____ 16. Copies of all certificates of title. (Example: Boats, Vehicles, Campers, etc.) _____ 17. Copies of all appraisals. _____ 18. Copies of all documents referenced or used to complete the 8.05 Financial Statement Form. Requested by ( ) mail ( ) fax or ( ) hand delivery on this the _____ day of __________, 20__. ________________________________ ________________________________ _________________________________ (Signature, address and telephone number of requesting party or his/her attorney) 8.05 FINANCIAL DECLARATION DOCUMENT PRODUCTION RESPONSE Pursuant to the 8.05 Financial Declaration Document Production Request form dated ______________________ and requested by____________________ ( name of opposing party or his/her attorney) I, _____________________ (name of party or attorney) certify that I have produced the following documents (check all that are produced). For those not produced, I certify that I do not have copies in my possession or control, nor are copies available to me upon reasonable request. If I have failed to produce documents for any other reason, those reasons are set forth below and correspond to each numbered request; and I certify that those reasons are true and correct. _____ 1. Copies of my past three (3) year’s Federal and State Income Tax returns, in full form as filed. _____ 2. A copy of your most recent Social Security Earnings Statement or a completed Form SSA-7050-F4. _____ 3. My most recent pay check stub. _____ 4. My most recent W-2's. _____ 5. All 1099's received by me in the past year. _____ 6. All K-1's received by me in the past year. _____ 7. Copies of the past three (3) year’s Federal and State Tax Income Tax returns, in full form as filed, for any partnership, limited liability company, corporation or limited partnership in which I own or have an interest _____ 8. Copies of my checking and saving account statements for the past twelve (12) months. _____ 9. Copies of my investment and brokerage account statements for the past twelve (12) months. _____ 10. Copies of my Certificates of Deposit, Bonds, or Stock. _____ 11. Copies of my IRA, 401(K), SEP, PERS, Pension, Deferred Compensation and any other retirement account for the past twelve (12) months. _____ 12. Copies of the declaration sheet for all life insurance policies owned by me or on which I have been a beneficiary for the past twelve (12) months. _____ 13. Copies of all credit card statements on which I have made charges for the past six (6) months. _____ 14. Copies of all loans, mortgages, promissory notes, or other documents showing debts owned by me, or debts owed to me by others. _____ 15. Copies of all deeds to real property. _____ 16. Copies of all certificates of title. (Example: Boats, Vehicles, Campers, etc.) _____ 17. Copies of all appraisals. _____ 18. Copies of all documents referenced or used to complete the 8.05 Financial Statement Form. Reason(s) for failure to produce documents requested in ______ (insert request number):_____________________________________________________________ ______________________________________________________________________ ____________________________________________________________________ Reason(s) for failure to produce documents requested in ______ (insert request number):______________________________________________________________ ______________________________________________________________________ ___________________________________________________________________ So CERTIFIED and PRODUCED by ( ) mail, ( ) fax, or ( ) hand delivered to: __________________________________ (other party or his/her attorney including full name, address and fax number) on this the _____ day of __________, 20__. ________________________________ ________________________________ ________________________________ (Signature, address and telephone number of producing party or his/her attorney)