Ind. DeKalb Cnty. Local Rules App., Appendix 1, Provisional Hearing Disclosure

STATE OF INDIANA ) SS: COUNTY OF DEKALB )

IN THE DEKALB CIRCUIT/SUPERIOR COURT II

CAUSE NO:

IN RE: THE MARRIAGE OF

Petitioner,

and

Respondent.

| HUSBAND: | | WIFE: | |

|---|---|---|---|

| Name: | | Name: | |

| Address: | | Address: | |

| | | | |

| Soc. Sec. No.: | | Soc. Sec. No.: | |

| Date of Birth: | | Date of Birth: | |

| Employer: | | Employer: | |

| Attorney: | | Attorney: | |

| Address: | | Address: | |

| | | | |

| Telephone No.: | | Telephone No.: | |

| GROSS WEEKLY INCOME: | AMOUNT Income |

|---|---|

| 1 Salary and Wages (Attach last 3 pay stubs) | |

| 2 Soc. Security/Disability/Unempl./Workers Comp/Pension/Retirement | |

| 3 Dividends and Interest | |

| 4 Rents/Royalties/Less Ordinary/Necessary Expenses | |

| 5 Business/Self-Employment Income-Less Ordinary Business Expenses | |

| 6 Commissions/Bonuses/Tips | |

| 7 All Other Sources | |

| 8 TOTAL GROSS WEEKLY INCOME (Total of Lines 1-7) | |

| WEEKLY DEDUCTIONS | Deductions |

|---|---|

| 9 Weekly Court Ordered Child Support for Prior Children | |

| 10 Weekly Legal Duty Child Support for Prior Children-attach CSOW | |

| 11 Weekly Health Insurance Premiums (Children of Marriage Only) | |

| 12 Weekly Alimony/Support Maintenance-Amount Actually Paid to Prior Spouses-Attach Copy of Order | |

| 13 Self-Employment Tax (1/2 of Weekly Self-Employment Taxes) | |

| 14 Work-Related Child Care Costs (Annual Amount Divided by 52) | |

| 15 Union Dues (Required for Employment) | |

The parties have the following marital debts/obligations:

| Debt/Obligation | Name of Creditor | Month/week or other amount |

|---|---|---|

| | | |

| 1. 1st Mortgage | | |

| 2. 2nd Mortgate | | |

| 3. Land Contract | | |

| 4. Rent | | |

| 5. Vehicle Payments: a) Make and Year: b) Make and Year: c) Make and Year: d) Make and Year: | | |

| 6. Vehicle Insurance - List for Each Vehicle: | | |

| 7. Credit Cards: a) b) c) d) e) f) | | |

| 8. Other Loan Payments: a) b) c) | | |

| 9. Other Marital Debts: | | |

| 10 Utilities at Marital Residence | |

|---|---|

| (a) Electricity | |

| (b) Gas | |

| (c) Fuel Oil | |

| (d) Water | |

| (e) Sewer | |

| (f) Water Softener | |

| (g) Local Telephone | |

| (h) Cellular Telephone | |

| (i) Cable Television/Internet | |

| (j) Garbage and Trash | |

I affirm, under penalties of perjury, that the foregoing representations are a true and accurate to the best of my knowledge and belief.

________ Petitioner/Respondent

Wife wants the following assets temporarily set aside to her:

Husband wants the following assets temporarily set aside to him: