Opinion
No. 89-R-99006-SCT.
October 28, 2010.
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.
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"
Not Real Estate
______________________________________ PLAINTIFF VS. ___________________________________ ______________________________________CIVIL ACTION NUMBER ________________________________ DEFENDANT _________________________________________________ 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 ( payroll deducted) 13. Medical 14. Dental 15. Child Care 16. Children's Allowance 17. Payment of child support/alimony Õ (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. 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 .................................... Equityt Note: List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under "V. LIABILITIES."Motor Vehicles Other Personal Property
B. 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. (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.Other Investments Life Insurance All Other Assets Note
Name(s) on Account Bank/Account Number Type Account Balance __________________________________________ ____________________ ________ __________________________________________ ____________________ ________ __________________________________________ ____________________ ________ TOTAL VALUE ________ E. (IRAs, stock(s), mutual funds, pension plans, etc.) Bank/Account Number Type Investment Balance __________________________ __________________________ ____________________ __________________________ __________________________ ____________________ __________________________ __________________________ ____________________ __________________________ __________________________ ____________________ __________________________ __________________________ ____________________ F. (exclude children) Insured Company Face Amount Cash Beneficiary ________________ _____________ _____________ _______ _______________ ________________ _____________ _____________ _______ _______________ ________________ _____________ _____________ _______ _______________ TOTAL CASH VALUE (less loans) _______ G. _________________________________ __________________________ _________________________________ __________________________ _________________________________ __________________________ TOTAL VALUE _____________________ TOTAL OF ALL ASSETS $__________________________ V. STATEMENT OF LIABILITIES (Include mortgage, car loan, credit cards, personal loans) : 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
_______________________________ DEFENDANT
_______________________________ CIVIL ACTION NUMBER
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 Amount of Monthly Child effect? (Yes or No) Support Order Payment B. Adult Children being supported by you Name Date of Birth Child Support Order in Amount of Monthly Child effect? (Yes or No) Support Order Payment5. 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. ______________________________________________________________________
SECTION II. INCOME
Unemployed Employed by:
1. My occupation is:________________________________________________ 2. I am currently: [_ all that apply] ____ a. 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. _______________________________________________________ 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.
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: _______________________________________________________________________ Retired.
____ c. 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: if known LAST YEAR'S ADJUSTED GROSS INCOME FROM TAX RETURN: if known LAST YEAR'S TAX REFUND FROM TAX RETURN: OUTSTANDING TAX LIABILITIES FROM TAX RETURN:
Your Income Other Party's Income () Year ________ $________ $_______ Your Income Other Party's Income () Year ________ $________ $_______ Federal Refund State Refund Year ________ $________ $_______ Federal State Year ________ $________ $_______Does the IRS or the State of Mississippi currently have a tax lien on any items of property?_______
If yes, please state the total amount of the tax lien and the items encumbered.
__________________________________________________________________
PRESENT MONTHLY GROSS INCOME: All amounts must be MONTHLY. Attach more paper, if needed. Items included under "other" should be listed separately with separate dollar amounts.
If you are paid on a schedule which is not monthly, you must convert those amounts. Conversion are as follows:
1. Paid Weekly, multiply by 4.33
2. Paid bi-weekly, multiply by 2.16
3. Paid on the 1th and 15th, or on 15th and 30th/31st, multiply by 2
4. Paid annually divide by 12 _________________ _________________ _________________ _________________ _________________ _________________ __________ _________________ ________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ PRESENT MONTHLY GROSS INCOME TOTAL: _________________
1. Monthly gross salary or wages 1.$ 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. 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. (Add lines 1-20) 21. PRESENT MONTHLY DEDUCTIONS: All amounts must be MONTHLY.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 1st and 15st, or on 15st, or on 15th and 30th/31st, multiply by 2
4. Paid annually divide by 12 TOTAL MONTHLY DEDUCTIONS: PRESENT NET MONTHLY INCOME
22. Present Monthly Federal Income Tax. 22.___________ 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. (Add lines 22 through 29) 31.___________ 32. (Total Gross Income minus Total Monthly Deductions) 32.___________ SECTION III. MONTHLY EXPENSES All amounts must be MONTHLY.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 1st and 15st, or on 15st and 30st/31st, multiply by 2
4. Paid annually divide by 12 A. HOUSEHOLD PRE-SEPARATION CURRENT PROPOSED/ESTIMATED EXPENSES ________ ______ _________ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ SUBTOTAL ________ ______ ______ B. VEHICLES AND BOATS ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ SUBTOTAL 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.) ________ ______ ______ ________ ______ ______ ________ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ 67. SUBTOTAL 67. ________ 67. ______ 67. ______ D. MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER RELATIONSHIP: (other than court-ordered child support) ________ ______ ______ ________ ______ ______ 71. SUBTOTAL 71. 71. ________ 71. ______ E. MONTHLY INSURANCE: ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ 78. SUBTOTAL 78. ________ 78. ______ 78. ______ F. OTHER MONTHLY EXPENSES NOT LISTED ABOVE: ________ ______ ______ ________ ______ ______ ________ ______ ______ ________ ______ ______ 83. SUBTOTAL 83. ________ 83. ______ 83. ______ 84. TOTAL MONTHLY EXPENSES: 84. 84. 84 . A. Liabilities SUMMARY: 85. TOTAL PRESENT MONTHLY NET INCOME 85. $______ 85. $____ 85. $____ 86. $______ 87. SURPLUS 88. (DEFICIT)
: : : 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. ________ 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. 35. 35. 35. 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. 44. _______ 44. ____ 44. ______ 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. 68. ______________________________ 68. _______ 68. _____ 68. ______ 69. ______________________________ 69. 69. 69. 70. ______________________________ 70. 70. 70. _____________ 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. 79. Other:______________________ 79. 79. 79. 80. Other:_________________________ 80. 80. 80. 81. Other:_________________________ 81. 81. 81. 82. Other:_________________________ 82. 82. 82. ________ _____ ______ (Add all expense Subtotals plus the monthly payments due on any liabilities that are listed in Section V., , that you have not listed in 1-84) (from line 32 of SECTION I. INCOME) 86. TOTAL MONTHLY EXPENSES (from line 84 above) 86. $____ 86. $____ (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. $____ (If line 86 is more than line 85, subtract line 85 from line 86. This is the amount of your deficit. Enter that amount here). 88.($______) 88.($____) 88.($____) SECTION IV. ASSETS 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. Equity (Fair Market Value minus Mortgage Balance) Equity (Fair Market Value minus Mortgage Balance) Equity (Fair Market Value minus Mortgage Balance) TOTAL EQUITY:_____________________ B. MODULAR/ MOBILE HOMES 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: $ $__________________ 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: $__________________ $________ Titled in the Name of: ________________________________________________ Comments: _____________________________________________________________ _______________________________________________________________________ 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: $_________________ $_______ Titled in the Name of: ________________________________________________ Comments: _____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 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. Equity: Equity: Equity: Equity: TOTAL EQUITY: _______________________ 1. Registered in the name of: ________________________ Year: Model: Mileage: ______________________ How Cost Paid: ____________________________________ Value: $________________________________________ Loan Balance: $_________________________________ $_____________________________ Printout Attached? ______ Yes ______ No 2. Registered in the name of: ________________________ Year: Model: Mileage: ______________________ How Cost Paid: ____________________________________ Value: $________________________________________ Loan Balance: $_________________________________ $_____________________________ Printout Attached? ______ Yes ______ No 3. Registered in the name of: ________________________ Year: Model: Mileage: ______________________ How Cost Paid: ____________________________________ Value: $________________________________________ Loan Balance: $_________________________________ $_____________________________ Printout Attached? ______ Yes ______ No 4. Registered in the name of: ________________________ Year: Model: Mileage: ______________________ How Cost Paid: ____________________________________ Value: $________________________________________ Loan Balance: $_________________________________ $_____________________________ Printout Attached? ______ Yes ______ No 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 TOTAL 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: $ ______ 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) FINANCIAL TYPE LAST FOUR(4) BALANCE 90 DAYS CURRENT ON ACCOUNT INSTITUTION OR OF ACCOUNT DIGITS ON THE PRIOR TO DATE OF BALANCE AS OF BANK NAME ACCOUNT COMPLAINT FILED __ __ __ // 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 NAME OF FINANCIAL TYPE OF LAST BALANCE 90 DAYS CURRENTBALANCE INVESTMENT INSTITUTION INVESTMENT FOUR (4) PRIOR TO DATE OF AS OF BROKERAGE FIRM DIGITS ON THE COMPLAINT FILED ETC. ACCOUNT 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 LIFE INSURANCE , , ___/___/__ TOTAL OTHER INVESTMENTS $______ Other Cash: Other Cash: TOTAL CASH $_________ H. PERSON OWNER OF COMPANY COVERAGE LOANS CASH LAST FOUR (4) BENEFICIARY INSURED POLICY AMOUNT VALUE DIGITS OF POLICY TOTAL $ CASH VALUEI. 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) FUTURE ASSETS Possible Value TOTAL OTHER ASSETS SUMMARY TOTAL ASSETS: $__________________________ (ADD Total from previous Sections A through J). 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: $ ______ SECTION V. LIABILITIES 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 PURPOSE/ REASON WHOSE NAME CURRENT MONTHLY WHO (4) DIGITS FOR DEBT IS LISTED ON BALANCE PAYMENT PAYS OF THE DEBT DUE DUE ACCOUNT TOTAL LIABILITIES 1 2 3 4 5 6 7 8 9 $ _____ $ _____ 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 SUMMARY TOTAL CONTINGENT LIABILITIES#$ ________ (ADD Total from previous Sections A through B). SECTION VI. SEPARATE PROPERTY and SEPARATE LIABILITIES TOTAL CONTINGENT LIABILITIES $ ________ 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. 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/ Hours Worked Pay Per Week Job Description 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, Cost or Monetary Value tax benefit or "perk" 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)