Mandatory Case Disclosure Page 4
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13Respondent stopped working for this employer on ________________.
(date)
Respondent stopped working for this employer because
Respondent earned $_________________ " every week, " every two weeks,
(dollar amount)
" twice a month, " once a month when Respondent left this employer.
Respondent " is " is not receiving unemployment compensation. If Respondent is
receiving unemployment, the amount received is $_________ per week.
(M) If Respondent is Disabled:
Respondent’s disability is
(describe disability)
" Respondent does not receive any disability income.
" Respondent receives $____________ per month from Social Security/S.S.I.
" Respondent receives $____________ per month from a private disability plan.
(N) If Respondent is Retired:
" Respondent receives $____________ per month from Social Security.
"
Respondent
receives
$____________
per
month
from
___________________________.
(name of retirement plan or fund)
(O) Does Respondent have any other sources of income?
Source(s):
Average Amount:
per " week, " month, " year.
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