Under penalty of perjury




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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY

For Official Use



IN THE INTEREST OF
     

Name


Statement of Income,

Assets, Debts and

Living Expenses


     

Date of Birth

Case No.      


Under penalty of perjury, I state that the following information on this financial statement is true, accurate and complete:

Print Name of Person Completing Form

     


Name of Father's Employer

     


Number of People in Household

      Adults       Children

Name of Mother's Employer

     





STATEMENT OF MONTHLY HOUSEHOLD INCOME

(If there are insufficient columns for all household members, attach additional schedules.)



Father

Mother

Other House-hold Members

Salary and wages (If weekly or biweekly, compute as a monthly figure.)

     

     

     

Other income: (Pensions, retirement, social security, disability, worker's compensation, public assistance)

     

     

     

Child support and/or maintenance from prior spouse

     

     

     

Dividends, interest, rents, bonuses

     

     

     

Other:      

     

     

     

Total Monthly Income

     

     

     

Itemized mandatory monthly deductions:

(Do not include savings or credit union deductions not required by law.)






Federal and state income taxes, social security, Medicare

     

     

     

Union or other dues

     

     

     

Retirement and pension funds

     

     

     

Other mandatory monthly deductions:

     

     

     

Total Mandatory Monthly Deductions

     

     

     

Net Monthly Income

     

     

     




STATEMENT OF ASSETS

Asset

Description

Fair Market/

Cash Value

Real estate (List kind of property and location)

     

     

Other real estate (List kind of property and location)

     

     

Vehicle (Give year and make)

     

     

Other vehicles (Give year and make)

     

     

Checking account (Give name of financial institution)

     

     

Savings account (Give name of financial institution)

     

     

IRA/Pensions/Profit Sharing (Identify by name)

     

     

Life insurance with cash value

(Identify by name of company)



     

     

Stocks/Bonds/Certificates of Deposit

     

     

Other assets valued over $200

     

     




Total Value of Assets

     






LONG TERM DEBTS AND MONTHLY EXPENSES




Long Term/Installment Debts

Creditor Name

Balance

Owed

Monthly Payment




Mortgage Payment (Include property taxes and insurance if included in payment.)

     

     

     




Credit Cards

     

     

     




Automobile Loans

     

     

     




Other:      

     

     

     




Other:      

     

     

     




Other:      

     

     

     







Total Owed

     







Other Monthly Debts/Expenses




Rent (Do not duplicate mortgage payment above.)

     




Repairs/maintenance on home

     




Food

     




Electricity/water/heat

     




Telephone

     




Laundry and dry cleaning

     




Child support paid for children not in your home

     




Maintenance paid to an ex-spouse

     




Clothing and shoes

     




Health insurance premiums

     




Medical/dental/drug expenses not covered by insurance

     




Life insurance premiums

     




Other insurance premiums (specify):      

     




Child care

     




Cable TV

     




Transportation costs (oil/gas/commuting)

     




School

     




Entertainment/incidentals/newspapers/books/periodicals

     




Hobbies

     




Other:      

     




Other:      

     




Other:      

     




Total Monthly Payments

     

Complete this form and return it to the juvenile court clerk so that it arrives by the time indicated on the court order.



Signature

     

Telephone Number







     

Date Signed







JD-1718, 08/07 Statement of Income, Assets, Debts and Living Expenses Chapters 48 and 938, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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