Financial Disclosure Statement
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1Dane County Clerk of Circuit Court
FINANCIAL DISCLOSURE STATEMENT
This application must be filled out completely – PLEASE PRINT.
Applications must be received within ten (10) days of conviction. Late applications may require a down payment.
A $15 fee is charged for the setting up and monitoring of a deferred payment agreement.
The fee must be paid at the time the deferred payment agreement is established.
FOR
FOR
FOR
FOR
FOR
RETURN THIS FORM WITH $_____________________ PAYMENT PLAN FEE AND
OFFICE USE
OFFICE USE
OFFICE USE
OFFICE USE
OFFICE USE
ONL
ONL
ONL
ONL
ONLY Y Y Y Y
$_____________________ DOWN PAYMENT BY:____________________________
CASE NUMBERS:
DATE
FIRST NAME
M.I.
LAST NAME
ARE YOU KNOWN BY ANY OTHER NAME:
WHAT OTHER NAME(S) ARE YOU KNOWN BY?
DATE OF BIRTH
YES
NO
DRIVER'S LICENSE NO.
SOCIAL SECURITY NO. (Disclosure of social security number is on a voluntary basis.
If disclosed, may be used for collection purposes.)
HOME STREET ADDRESS
CITY, STATE, ZIP CODE
PHONE
NAME OF EMPLOYER/BUSINESS
RECEIVING THE
CHILD SUPPORT
SS
VA BENEFITS
FOLLOWING:
PENSION
SSDI
UNEMPLOYMENT
EMPLOYER STREET ADDRESS, CITY, STATE, ZIP
PHONE
OCCUPATION
NUMBER OF HOURS WORKED
HOURLY RATE
PER WEEK
NUMBER OF LEGAL DEPENDENTS (CHILDREN)
MARITAL STATUS:
IS YOUR SPOUSE/SIGNIFICANT OTHER EMPLOYED?
MARRIED
UNMARRIED
SEPARATED
YES
NO
SPOUSE'S OR SIGNIFICANT OTHER’S PLACE OF EMPLOYMENT:
DO YOU CURRENTLY HAVE A PAYMENT PLAN WITH THE COURT?
YES
NO
1. TOTAL NET INCOME PER MONTH FROM ALL SOURCES
(Includes spouse or significant other’s income) ................................................... $______________
ALLOWABLE EXPENSES PER MONTH:
A. HOUSING (Rent/Mortgage) .......................................... + $______________
B. OTHER COURT ORDERED PAYMENTS ...................... + $______________
(Explain:_____________________________________________________)
C. FOOD ................................................................................ $______________
2. TOTAL ALLOWABLE EXPENSES (Add lines A, B, C) ........... ($_____________)
3. TOTAL MONTHLY NET ADJUSTED INCOME (Subtract line 2 from line 1) ....... $______________
4. AMOUNT YOU BELIEVE YOU CAN PAY PER MONTH .................................... $______________
080-649-4 (11/09)
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