IN THE CIRCUIT COURT FOR
COUNTY, (STATE)

	CASE NO.:

Petitioner,	PRE-HEARING STATEMENT
vs.

Respondent.

1. PERSONAL INFORMATION:

		HUSBAND	WIFE
Full Name
Present Mailing Address


Employer
Street Address
City, State, ZIP
Birth Date		(age)	(age)
Marriage Date
Separation Date (Different Residence)
Date(s) of Temporary Order(s), if any
Minor Children born to this marriage or who will be affected by this legal action
FULL NAME	BIRTH DATE	AGE	LIVING WITH




Is the wife now pregnant? NO YES - due date of
Is the issue of custody contested? NO YES
If custody is disputed, each party shall submit proposals for custody and visitation for each child as EXHIBIT 1A.

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

2. EMPLOYMENT: Provide the following data for each employer.

			HUSBAND	WIFE
a)	Name of Employer
	Length of Employment
	Income:
	(1)	Gross income per
		Statutory Deductions:
		Federal Income Tax
		State Withholding
		Social Security (FICA)
		Pension Deductions
		Union Dues
		Dependent Health/ Hospitalization Coverage
		Dental Coverage
	(2)	Subtotal of Statutory Deductions:
	(3)	Net Income (line 1 - line 2)
		Other Paycheck Deductions:
		Specify:

	(4)	Subtotal of other Deductions:
	(5)	NET TAKE-HOME PAY PER (line 3 - line 4)
Tax withholding figures above are based upon married or single taxpayer with # of exemptions: (example: M-4 or S-2)
Attach prior month's paycheck stub(s) as EXHIBIT 2A.
b)	Employee Benefits: Identify all benefits in addition to wages, including bonus paid or due, automobile or travel expense reimbursement, other per diem compensation, memberships paid by the employer.



Will your medical and dental insurance coverage be available for your spouse after the dissolution? YES NO

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

			HUSBAND	WIFE
(c)	Other Income:		$	$
	(1)	Public Assistance (AFDC/GA)	$	$
	(2)	Social Security benefits for party or child/children	$	$
	(3)	Unemployed/Workers Comp.	$	$
	(4)	Interest income per	$	$
	(5)	Dividend income per	$	$
	(6)	Other Income:	$	$
	(7)	Last Year's Tax Refunds	Federal	Federal
			State	State

3. CHILD SUPPORT/ALIMONY:

a) Does either party receive child support or alimony from a separate proceeding?

Yes No

If yes, specify the $ received each month for child support/alimony for by the order of County, dated .

b) Child Support or alimony established by court order for person(s) not included in this proceeding currently being paid:

To Whom is this obligation owed?
County and Date of Such Order:

c) Current Monthly Child Support or alimony Order established by temporary order for other party and minor children in this proceeding:
Child Support: $ Alimony: $
Any claimed arrearages under existing court order(s)? Yes No
If Yes, specify amount(s) claimed:

	Child Support:$
	Spousal Maintenance (Alimony)$

4. LIVING EXPENSES:

Your estimated monthly expenses: $
(Enter the total from an itemized schedule to be attached as EXHIBIT 4A.)

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

5. REAL PROPERTY:

		HOMESTEAD	OTHER*
a)	Date acquired	$	$
b)	Purchase Price	$	$
c)	Present Fair Market Value	$	$
d)	First Mortgage Balance	$	$
e)	Second Mortgage Balance or Home Improvement Loan	$	$
f)	Net Value	$	$
g)	Monthly Payment: (PITI)	$	$
h)	Rental income, if any	$	$
* Other Real Estate: Provide the same information for other real property such as rental property, lake cabin, etc. as EXHIBIT 5C.

6. PERSONAL PROPERTY: Fair Market Value

In Possession of:		HUSBAND	WIFE	JOINT
a)	Household Contents	$	$	$
b)	Stocks, Bonds, etc.	$	$	$
		$	$	$
c)	Checking Accounts	$	$	$
		$	$	$
	Savings Accounts	$	$	$
		$	$	$
d)	Receivables and Claims	$	$	$
		$	$	$
e)	Motor Vehicles:
(1)year/make/model (2)year/make/model (3)year/make/model
	Market Value	$	$	$
	Encumbrance	$	$	$
	Net Value	$	$	$
	Monthly Payment	$	$	$
	In Possession of
f)	Boats, Motors, Campers, Snowmobiles, Trailer, etc.:
(1) year/make/model (2) year/make/model (3) year/make/model
	Market Value	$	$	$
	Encumbrance	$	$	$
	Net Value	$	$	$
	Monthly Payment	$	$	$
	In Possession of

This is not a substitute for legal advice. An attorney must be consulted.
Copyright © 1994 - 2015 by LAWCHEK, LTD.

g)	Other: (Such as Power Equipment, Tools, Guns, Valuable Animals, etc.)
	Description:	Fair Market Value $ Encumbrance $ Net Value $

7. NON-MARITAL CLAIMS:

a)	Description:	(1)	(2)
b)	Amount claimed:	$	$

Set forth as the basis for and method used to arrive at your claims to be attached as EXHIBIT 7A.

8. LIFE INSURANCE:

	a)	b)	c)
Company
Policy Number
Type of Insurance
Face Amount	$	$	$
Cash Value	$	$	$
Loans	$	$	$
Insured
Beneficiary
Owner

9. PENSION PLAN AND/OR PROFIT SHARING PLAN:

			HUSBAND	WIFE
a)	Through Employment:
	(1)	Present Cash Value	$	$
	(2)	Vested or Non-vested
b)	Private Plans
		(IRA, Keogh, SEP, etc.)
	(1)	Present Cash Value	$	$
c)	Deferred Compensation:		$	$
d)	Military Pension or Disability		Yes No	Yes No

10. DEBTS: (Not Listed in Paragraphs 4 or 5 above)

a)	All Secured Debts:	HUSBAND	WIFE	JOINT
	Creditor
	Total Amount Owing	$	$	$
	Monthly Payment	$	$	$
	When Incurred

	Party Obligated (H, W, J)
	Reason for Debt
	Totals	$	$	$
b)	Unsecured Debts: Attach a separate schedule showing the creditor, balance owed, monthly payments, etc., to be attached as EXHIBIT 10B. Include attorney fees and costs.
	Totals:	$	$	$

Dated:

The statements contained herein are true
and complete to the best of my knowledge.

Petitioner

Respondent


	(Attorney)
Attorney for	Attorney I.D.#
(Address)
Telephone #: