Financial Disclosure Statement Template

In the [Name of Court] Court of [County], [State]
Case No.: __________________________

Petitioner: [Full Name]
Respondent: [Full Name]

1. Personal Information

Full Name: [Full Name]
Address: [Street, City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
Occupation: [Job Title/Employer Name]
Date of Birth: [MM/DD/YYYY]

2. Income

• Gross Monthly Income: $[Amount]

• Net Monthly Income (after taxes): $[Amount]

• Source(s) of Income: [Employer, Self-Employment, Investments, Benefits, etc.]

• Additional Income (bonuses, commissions, alimony, child support): $[Amount]

3. Assets

A. Real Estate:
[List all properties owned, including primary residence, rental, or vacation properties.]
Address: __________________________
Fair Market Value: $[Amount]
Mortgage Balance: $[Amount]
Equity: $[Amount]

B. Vehicles:
Make/Model: __________________________
Year: _______ Value: $[Amount] Loan Balance: $[Amount]

C. Bank Accounts:
Bank Name: __________________________
Account Type: [Checking/Savings/Other]
Balance: $[Amount]

D. Investments and Retirement:
Type: [Stocks/Bonds/401(k)/IRA/etc.]
Institution: __________________________
Current Value: $[Amount]

E. Personal Property:
Description: [Furniture, Jewelry, Art, etc.]
Estimated Value: $[Amount]

4. Debts and Liabilities

A. Credit Cards:
Card Issuer: __________________________
Balance: $[Amount] Monthly Payment: $[Amount]

B. Loans:
Type: [Auto/Student/Personal/Other]
Lender: __________________________
Balance: $[Amount] Monthly Payment: $[Amount]

C. Other Debts:
[List any additional financial obligations, such as medical bills or tax debts.]

5. Monthly Expenses

Housing (rent/mortgage): $[Amount]
Utilities: $[Amount]
Transportation: $[Amount]
Food and Groceries: $[Amount]
Insurance (health, life, auto): $[Amount]
Childcare or School: $[Amount]
Miscellaneous: $[Amount]

6. Supporting Documentation

Attach copies of:
☐ Most recent pay stubs (last 2 months)
☐ Previous year’s federal and state tax returns
☐ Bank statements (last 3 months)
☐ Mortgage or loan statements
☐ Any additional proof of income or assets

7. Certification

I declare under penalty of perjury under the laws of the State of [State] that the information contained in this Financial Disclosure Statement is true, complete, and correct to the best of my knowledge.

Signature: __________________________
Printed Name: __________________________
Date: __________________________

Notary Acknowledgment

State of [State]
County of [County]

Subscribed and sworn before me on this _____ day of __________, 20____, by [Full Name].

Notary Public Signature: __________________________
Commission Expires: __________________________
Seal: