Mandatory Case Disclosure Page 2
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13" Petitioner is paid a salary. Petitioner receives $_____________________________
(amount of pay check before taxes)
" every week, " every two weeks, " twice a month, " once a month.
(F) If Petitioner is Unemployed:
Name of Last Employer:
Address of Last Employer:
Petitioner stopped working for this employer on ________________.
(date)
Petitioner stopped working for this employer because
Petitioner earned $_________________ " every week, " every two weeks, " twice a
month,
" once a month when Petitioner left this
(dollar amount)
employer.
Petitioner " is " is not receiving unemployment compensation. If Petitioner is receiving
unemployment, the amount received is $_________ per week.
(G) If Petitioner is Disabled:
Petitioner’s disability is
(describe disability)
" Petitioner does not receive any disability income.
" Petitioner receives $____________ per month from Social Security/S.S.I.
" Petitioner receives $____________ per month from a private disability plan.
(H) If Petitioner is Retired:
" Petitioner receives $____________ per month from Social Security.
" Petitioner receives $____________ per month from ___________________________.
(name of retirement plan or fund)
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