Certificate Of Compliance With Mandatory Disclosure - Florida Circuit Court Page 4
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) Florida Family Law Rules of Procedure Form 12.902(c) (long form)
b. ____ All personal (1040) federal and state income tax returns, gift tax returns, and
intangible personal property tax returns for the preceding 3 years;
(
) IRS forms W-2, 1099, and K-1 for the past year because the income tax return
for the past year has not been prepared.
c. ____ Pay stubs or other evidence of earned income for the 3 months before the service of the
financial affidavit.
d. ___
A statement identifying the source and amount of all income for the 3 months before
the service of the financial affidavit, if not reflected on the pay stubs produced.
e. ___
All loan applications and financial statements prepared for any purpose or used for any
purpose within the 12 months preceding the service of the financial affidavit.
f. ___
All deeds to real estate in which I presently own or owned an interest within the
past 3 years. All promissory notes in which I presently own or owned an interest
within the last 12 months. All present leases in which I own an interest.
g. ___
All periodic statements for the last 3 months for all checking accounts and for the last
year for all savings accounts, money market funds, certificates of deposit, etc.
h. ___
All brokerage account statements for the last 12 months.
i. ___
Most recent statement for any pension, profit sharing, deferred compensation, or
retirement plan (for example, IRA, 401(k), 403(b), SEP, KEOGH, etc.) and summary plan
description for any such plan in which I am a participant or alternate payee.
j. ___
The declaration page, the last periodic statement, and the certificate for any group
insurance for all life insurance policies insuring my life or the life of me or my spouse.
k. ___
All health and dental insurance cards covering either me or my spouse and/or our
dependent child(ren).
l. ___
Corporate, partnership, and trust tax returns for the last 3 tax years, in which I have an
ownership or interest greater than or equal to 30%.
m. ___
All credit card and charge account statements and other records showing my (our)
indebtedness as of the date of the filing of this action and for the prior 3 months. All
promissory notes on which I presently owe or owned within the past year. All lease
agreements I presently owe.
n. ___
All premarital and marital agreements between the parties to this case.
o. ___
If a modification proceeding, all written agreements entered into between the parties
at any time since the order to be modified was entered.
p. ___
All documents and tangible evidence relating to claims for an unequal distribution of
marital property, enhancement or appreciation in nonmarital property, or nonmarital
status of an asset or debt.
q. ___
Any court order directing that I pay or receive spousal support (alimony) or child
support.
I certify that a copy of this document was [check all used]: ( ) e-mailed ( ) mailed
( ) faxed ( ) hand delivered to the person(s) listed below on {date}_________________.
Other party or his/her attorney:
Name: _______________________________________
Address: ______________________________________
City, State, Zip: _________________________________
Fax Number: ___________________________________
E-mail Address(es):_______________________________
Florida Family Law Rules of Procedure Form 12.932, Certificate of Compliance with Mandatory Disclosure (09/12)
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