Complaint For Divorce Page 20
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37Assets which are used for support of family
$ ______________
Fringe Benefits (if significantly reduce living expenses)
$ ______________
Any other income (do NOT include means-tested
Public assistance, such as TANF or food stamps)
$ ______________
GROSS MONTHLY INCOME
$ ______________
(prior section B deleted)
B. Affiant’s Net Monthly Income from employment
(deducting only state and federal taxes and FICA)
$ _______________
Affiant’s pay period (i.e., weekly, monthly, etc.) ___________________
Number of exemptions claimed ____________
4. ASSETS
(If you claim or agree that all or part of an asset is non-marital, indicate the non-marital portion
under the appropriate spouse’s column and state the amount and the basis: pre-marital, gift,
inheritance, source of funds, etc.).
Description
Value
Separate Asset
Separate Asset
Basis of the
of the Husband
of the Wife
Claim
Cash
$____________ ______________ ______________ ____________________
Stocks, bonds
$____________ ______________ ______________ ____________________
CD’s/Money Market
$____________ ______________ ______________ ____________________
Accounts
Bank Accounts
(list each account):
_______________
$____________ ______________ ______________ ____________________
_______________
$____________ ______________ ______________ ____________________
_______________
$____________ ______________ ______________ ____________________
Retirement Pensions,
401K, IRA, or
$____________ ______________ ______________ ____________________
Profit Sharing
Money owed you:
$____________ ______________ ______________ ____________________
Tax Refund
owed you:
$____________ ______________ ______________ ____________________
20
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