| STOCKBRIDGE-MUNSEE TRIBAL COURT | ||||
| Mohican Nation | Stockbridge-Munsee
Community |
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| Date: -- | ) | |||
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| , | ) | Case No: | ||
| Petitioner, | ) | |||
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FINANCIAL DISCLOSURE FORM |
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| Respondent. | ) | |||
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Important Required Information |
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| Husband | Wife | |
| Home Address: | ||
| S.S. Number: | ||
| Birth date: | ||
| Employer: | ||
| Occupation: | ||
| Date of Marriage: | ||
| Date of Separation: | ||
| Statement of Income | ||
| Husband | Wife | |
| Gross Monthly Income - Salary: | $ | $ |
| Total Gross Monthly Income: | $ | $ |
| Monthly Deductions for Gross Income | ||
| Husband | Wife | |
| Monthly Deductions from Gross Income: | $ | $ |
| Taxes - State: | $ | $ |
| Taxes - Federal: | $ | $ |
| Taxes - Social Security: | $ | $ |
| Insurance: | $ | $ |
| 401 K Loan (Home Improvements): | $ | $ |
| Retirement: | $ | $ |
| Credit Union: | $ | $ |
| Maintenance: | $ | $ |
| Total Monthly Deductions: | $ | $ |
| Net Monthly Income (Take Home Pay): | $ | $ |
| Statement of Monthly Marital Expenses | ||
| Husband | Wife | |
| Name of Expense | $ | $ |
| Rent/Mortgage Payments: | $ | $ |
| Food: | $ | $ |
| Utilities: | $ | $ |
| Clothing: | $ | $ |
| Laundry: | $ | $ |
| Medical Not Covered by Insurance: | $ | $ |
| Dental Not Covered by Insurance: | $ | $ |
| Insurance: | $ | $ |
| Automobile Expense: | $ | $ |
| Auto Payments: | $ | $ |
| Debts: | $ | $ |
| Total Monthly Marital Expenses: | $ | $ |
| Statement of Marital Assets | ||
| Husband | Wife | |
| Residence (Appraised Value): | $ | $ |
| Automobiles: | $ | $ |
| Personal Property: | $ | $ |
| Jewelry (Appraised Value): | $ | $ |
| Checking Account (Name of Bank): | $ | $ |
| Cash at Commencement of Action: | $ | $ |
| Pension: | $ | $ |
| Other: | $ | $ |
| $ | $ | |
| Total Marital Assets: | $ | $ |
| Statement of Marital Liabilities | ||
| Husband | Wife | |
| Mortgage: | $ | $ |
| Credit Cards: | $ | $ |
| Loans: | $ | $ |
| Total Marital Liabilities: | $ | $ |
| Summary | ||
| Husband | Wife | |
| Total Marital Assets: | $ | $ |
| Total Marital Liabilities: | $ | $ |
| Total Net Marital Estate: | $ | $ |
| Assets | ||
| Husband | Wife | |
| Residence: | $ | $ |
| Automobiles: | $ | $ |
| Personal Property: | $ | $ |
| Jewelry (Appraised): | $ | $ |
| Checking Account: | $ | $ |
| Cash at Commencement of Action: | $ | $ |
| Pensions: | $ | $ |
| Other Property: | $ | $ |
| $ | $ | |
| Totals: | $ | $ |
| Liabilities | ||
| Husband | Wife | |
| Mortgage: | $ | $ |
| Credit Cards: | $ | $ |
| Loans: | $ | $ |
| $ | $ | |
| Totals: | $ | $ |
| Net Marital Estate: | $ | |
| Total Share of Net Estate: | $ | |
Other Issues to be decided by the Court:
1.
2.
Husband's Signature:
Husband's Printed Name:
Date:
Wife's
Signature:
Wife's Printed Name:
Date: