La Crosse County Child Support Financial Disclosure
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1
2LA CROSSE COUNTY CHILD SUPPORT
FINANCIAL DISCLOSURE
IVD:________________
You are required by law to fill out this form. Failure to do so completely and accurately constitutes perjury
(a class H felony) punishable by up to six years in prison and/or a $10,000 fine.
If more space is needed in any section, please attach an additional sheet.
Name
: ___________________________________________e-mail address:_______________________
Social Security #: ________________________ Age: _____ DOB: _____________
Address: _____________________________ City: __________State _____ Zip: ______
Home phone: ___________________Cell phone: _____________ Work:____________
Employer: ____________________________Occupation: ________________________
Employer phone#: _____________________Employer fax #:______________________
Highest degree completed (check one): ____ Some High School ____ GED/HS Diploma
___ Some Technical/College ___Two Year Degree ___ Four Year Degree
__Postgraduate/professional
Please indicate course of study: ____________________
Child(ren)s Name(s) – Please list only your natural children – not step children
Date of Birth
Age
________________________________________
__________________
______
________________________________________
__________________
______
________________________________________
__________________
_______
________________________________________
__________________
_______
Attach copies of your wage stubs for the past eight (8) weeks and tax returns for the last two years,
including all schedules and W2 forms.
Indicate types and amounts of income below.
Gross monthly income from wage earnings : $_______________________
(If you have a weekly income, multiply it by 4.33. If you have a bi-weekly income,
multiply it by 2.17.)
Indicate sources and monthly amounts of other income:
Public Assistance __________Social Security _____________ Disability___________
Rental Income_____________ Unemployment ____________ Child Support_________
Pension __________Other (List other source)___________________________________
Tribal Affiliation __________________________ , Tribal Income (Per Cap)$_____________/mo
*Military Rank ______________ Year of Service Entry ________Branch of Service__________
lease include your Military Leave and Earnings Statement*
*P
Total Monthly income $___________________
Assets/Liabilities:
Real Estate
1.Address: __________________________________________________________
Single family home ____
Rental Property ____
Business Property ____
Original Cost _________ Mortgage Balance ________ Current Market Value _______
2.Address: __________________________________________________________
Single family home ____
Rental Property ____
Business Property ____
Original Cost _________ Mortgage Balance ________ Current Market Value _______
Business Interests:
Type
Percent
Equity
Name of business & address of business
Ownership
____________________________ __________
_______
___________
____________________________ __________
_______
___________
____________________________ __________
_______
___________
12/14/15
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