Petition For Dissolution Of Marriage Page 5
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94.
Worker’s Compensation:
0.00
5.
Social Security/SSI:
0.00
6.
TANF: (TANF is "Temporary Assistance for
0.00
Needy Families")
7.
Child Support:
0.00
8.
Maintenance:
0.00
9.
Retirement Benefits:
0.00
10.
Others (list all and give amounts):
_________________
D. CHILD SUPPORT GUIDELINE INFORMATION:
1.
Medical Insurance:
Who pays:
______________________________________________________
How paid:
________________________________________________________
How Much for Child(ren) Only:
per month
2.
Dental Insurance:
Who pays:
_______________________________________________________
How paid:
________________________________________________________
How Much for Child(ren) Only:
per month
3.
Child Care Costs:
Who Provides:
_____________________________________________________
How Often is Provider Paid:
__________________________________________
Name of Provider:
__________________________________________________
How Much Paid:
4. Amount Paid for Court Ordered Child Support for Prior Born Child(ren):
5. Amount Paid for Court Ordered Maintenance for Prior Marriage(s):
6. Imputed Child Support for Prior Born Child(ren):
7. Child Support Received for Child not of this Marriage:
8. Maintenance Received from Prior Marriage:
E. NONMARITAL PROPERTY CLAIMS:
List all property, real or personal, tangible or intangible, of greater than $100.00 in value, which you claim to be
either entirely or partially your nonmarital property.
_________________F. MARITAL PROPERTY:
1.
Real Property:
Address
Fair Market Value
Mortgage(s) Balance
% Interest
None
2. Vehicles, Motorcycles, Boats, Trailers, Equipment, etc.:
Year/Make/Model/Type
Fair Market Value
Loan Balance
None
3. Bank Accounts*
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