Ind. DeKalb Cnty. Local Rules App., Appendix 3, Final 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 TOTAL GROSS WEEKLY INCOME (Total of Lines 1-6) | |

| WEEKLY DEDUCTIONS | Deductions |

|---|---|

| 8 Weekly Court Ordered Child Support for Prior Children | |

| 9 Weekly Legal Duty Child Support for Prior Children-attach CSOW | |

| 10 Weekly Health Insurance Premiums (Children of Marriage Only) | |

| (a) Medical | |

| (b) Dental | |

| (c) Optical | |

| 11 Weekly Alimony/Support Maintenance-Amount Actually Paid to Prior Spouses-Attach Copy of Order | |

| 12. Self-Employment Tax (1/2 of Weekly Self-Employment Taxes) | |

|---|---|

| 13. Work-Related Child Care Costs (Annual Amount Divided by 52) | |

| 14. Union Dues (Required for Employment) | |

| 15. Name - If Wife wants Former Name Restored - State Full Name: |

|---|

| |