Preliminary Verified Disclosure Statement Page 7
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8AOC-238
Rev 1-11
Page 7 of 8
G.
DEBTS*:
Creditor
Purpose/Security
Balance
Monthly Pmt.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets, periodic statements from
investments, statements on life insurance, periodic statements from retirement plans, periodic statements reflecting assets
held in name of or on behalf of children, and documents reflecting debts and credit card statements for past 12 months should
be in possession of answering party or answering party’s attorney when this statement is served on the opposing party.
H.
MONTHLY EXPENSES (Specify amounts):
Actual
Anticipated
Rent:
_______________________________________________________________________________________________
Mortgage:
_______________________________________________________________________________________________
Property Tax:
_______________________________________________________________________________________________
Homeowner’s/Renter’s Insurance:
_______________________________________________________________________________________________
House Maintenance:
_______________________________________________________________________________________________
Electric Utilities:
_______________________________________________________________________________________________
Fuel, Oil, Gas Utilities:
_______________________________________________________________________________________________
Telephone:
_______________________________________________________________________________________________
Cellular Phone:
_______________________________________________________________________________________________
Water and Sewer:
_______________________________________________________________________________________________
Garbage Pickup:
_______________________________________________________________________________________________
Yard Expense:
_______________________________________________________________________________________________
Cleaning Service:
_______________________________________________________________________________________________
Child Care/Babysitter:
_______________________________________________________________________________________________
Cable Television:
_______________________________________________________________________________________________
Car Payments/Lease Payments:
_______________________________________________________________________________________________
Auto Gas and Oil:
_______________________________________________________________________________________________
Car Maintenance and Repairs:
_______________________________________________________________________________________________
Car Licenses/Taxes
_______________________________________________________________________________________________
Car Insurance:
_______________________________________________________________________________________________
Religious/Charitable Contributions:
_______________________________________________________________________________________________
Clothing:
_______________________________________________________________________________________________
Uniforms:
_______________________________________________________________________________________________
Dry Cleaners:
_______________________________________________________________________________________________
Entertainment:
_______________________________________________________________________________________________
Gifts:
_______________________________________________________________________________________________
Food:
_______________________________________________________________________________________________
Doctor:
_______________________________________________________________________________________________
Dentist:
_______________________________________________________________________________________________
Orthodontist:
_______________________________________________________________________________________________
Prescriptions Drugs/Medicines:
_______________________________________________________________________________________________
Optometrist/Ophthalmologist/Eyeglasses:
_______________________________________________________________________________________________
Medical/Dental Insurance (not deducted from pay):
_______________________________________________________________________________________________
Life Insurance (not deducted from pay):
_______________________________________________________________________________________________
Disability Insurance (not deducted from pay):
_______________________________________________________________________________________________
Newspaper:
_______________________________________________________________________________________________
Magazine Subscriptions:
_______________________________________________________________________________________________
Veterinarian/Pet Food:
_______________________________________________________________________________________________
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