Disclosure Statement Page 5
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8(Rev. 6/07/06) CCDR 0604 E
Case No.___________________________
RECAPITULATION
NET MONTHLY INCOME
$ ______________________________
TOTAL MONTHLY LIVING EXPENSES
______________________________
DIFFERENCE BETWEEN NET INCOME AND EXPENSES
______________________________
LESS MONTHLY DEBT SERVICE
______________________________
INCOME AVAILABLE PER MONTH
______________________________
CONTINGENT LIABILITIES:
(Provide potential obligor, claimant, basis of claim, date incurred, amount claimed, who incurred.)
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Have you ever filed for Bankruptcy? _________ Yes _________ No
Is so, when?
Date ________________ Case No. ___________________________
Additional Cash Flow (monthly) (Identify but do not add to monthly income)
Spousal Support Received
(Payments received from prior Judgment or Support orders in other actions):
_________________________________
Case No. _________________________________
Child Support Received
(Payments received pursuant to Court order in this action):
_____________________________
(Payments received pursuant to Court order in other actions):
_____________________________
Case No.: _____________________________
STATEMENT OF ASSETS
The date of valuation is _______________________ _______ unless otherwise specified. Please designate values. In prejudg-
ment dissolution of marriage actions, please indicate whether the property is marital (M) or non-marital husband (NMH)
or non-marital wife (NMW).
Description of Asset
Title in Name of
M/NMH/NMW
Value
CASH or CASH EQUIVALENTS:
1.
Savings or interest-bearing accounts
2.
Checking Accounts
3.
Certificates of Deposit
4.
Money Market Accounts
5.
Cash
6.
Other (specify):
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