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                                                      

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

 

 
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 #:                            

 

 

 

 

 

 

 

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


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

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