Fillable FDF Attorney for Nevada State Bar No. (Family Law Self Help Center)

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FDF Attorney for Nevada State Bar No. (Family Law Self Help Center)

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FDF
Name:
Address:
Phone:
Email:
Attorney for
Nevada State Bar No.
_________ Judicial District Court
____________________, Nevada
GENERAL FINANCIAL DISCLOSURE FORM
A. Personal Information:
1. What is your full name? (first, middle, last)
2. How old are you? 3.What is your date of birth?
4. What is your highest level of education?
B. Employment Information:
1. Are you currently employed/ self-employed? (
check one)
No
Yes If yes, complete the table below. Attached an additional page if needed.
2. Are you disabled? (
check one)
No
Yes If yes, what is your level of disability?
What agency certified you disabled?
What is the nature of your disability?
C. Prior Employment: If you are unemployed or have been working at your current job for less than 2 years,
complete the following information.
Prior Employer: ___________________ Date of Hire: ___________ Date of Termination:
Reason for Leaving:
Plaintiff,
vs.
Defendant.
Case No.
Dept.
Date of Hire
Employer Name
Job Title
Work Schedule
(days)
Work Schedule
(shift times)
Rev. 8-1-2014 Page 1 of 8
Monthly Personal Income Schedule
A. Year-to-date Income.
As of the pay period ending ________________ my gross year to date pay is _____________.
B. Determine your Gross Monthly Income.
Hourly Wage
×
=
×
52
Weeks
=
12
Months
=
Hourly
Wage
Number of hours
worked per week
Weekly
Income
Annual
Income
Gross Monthly
Income
Annual Salary
÷
12
Months
=
Annual
Income
Gross Monthly
Income
C. Other Sources of Income.
Source of Income Frequency Amount
12 Month
Average
Annuity or Trust Income
Bonuses
Car, Housing, or Other allowance:
Commissions or Tips:
Net Rental Income:
Overtime Pay
Pension/Retirement:
Social Security Income (SSI):
Social Security Disability (SSD):
Spousal Support
Child Support
Workman’s Compensation
Other: ______________________
Total Average Other Income Received
Total Average Gross Monthly Income (add totals from B and C above)
Page 2 of 8
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
D. Monthly Deductions
Business/Self-Employment Income & Expense Schedule
A. Business Income:
What is your average gross (pre-tax) monthly income/revenue from self-employment or businesses?
$_______________
B. Business Expenses: Attach an additional page if needed.
Type of Deduction Amount
1.
Court Ordered Child Support (automatically deducted from paycheck)
2.
Federal Health Savings Plan
3.
Federal Income Tax
4.
Amount for you: _____________________
Health Insurance For Opposing Party:___________________
For your Child(ren):__________________
5.
Life, Disability, or Other Insurance Premiums
6.
Medicare
7.
Retirement, Pension, IRA, or 401(k)
8.
Savings
9.
Social Security
10.
Union Dues
11.
Other: (Type of Deduction) ______________________________
Total Monthly Deductions (Lines 1-11)
Type of Business Expense Frequency Amount 12 Month Average
Advertising
Car and truck used for business
Commissions, wages or fees
Business Entertainment/Travel
Insurance
Legal and professional
Mortgage or Rent
Pension and profit-sharing plans
Repairs and maintenance
Supplies
Taxes and licenses
(include est. tax payments)
Utilities
Other:___________________________
Total Average Business Expenses
Page 3 of 8
0.00
0.00
0.00
Personal Expense Schedule (Monthly)
A. Fill in the table with the amount of money you spend each month on the following expenses and
check whether you pay the expense for you, for the other party, or for both of you.
Expense Monthly Amount I Pay
For Me
Other Party
For Both
Alimony/Spousal Support
Auto Insurance
Car Loan/Lease Payment
Cell Phone
Child Support (not deducted from pay)
Clothing, Shoes, Etc…
Credit Card Payments (minimum due)
Dry Cleaning
Electric
Food (groceries & restaurants)
Fuel
Gas (for home)
Health Insurance (not deducted from pay)
HOA
Home Insurance (if not included in mortgage)
Home Phone
Internet/Cable
Lawn Care
Membership Fees
Mortgage/Rent/Lease
Pest Control
Pets
Pool Service
Property Taxes (if not included in mortgage)
Security
Sewer
Student Loans
Unreimbursed Medical Expense
Water
Other:______________________________
Total Monthly Expenses
Page 4 of 8
0.00
Household Information
A. Fill in the table below with the name and date of birth of each child, the person the child is living
with, and whether the child is from this relationship. Attached a separate sheet if needed.
B. Fill in the table below with the amount of money you spend each month on the following expenses
for each child.
C. Fill in the table below with the names, ages, and the amount of money contributed by all persons
living in the home over the age of eighteen. If more than 4 adult household members attached a
separate sheet.
Child’s Name
Child’s
DOB
Whom is this
child living
with?
Is this child
from this
relationship?
Has this child been
certified as special
needs/disabled?
1
st
2
nd
3
rd
4
th
Type of Expense
1
st
Child
2
nd
Child
3
rd
Child
4
th
Child
Cellular Phone
Child Care
Clothing
Education
Entertainment
Extracurricular & Sports
Health Insurance
(if not deducted from pay)
Summer Camp/Programs
Transportation Costs for Visitation
Unreimbursed Medical Expenses
Vehicle
Other:__________________________
Total Monthly Expenses
Name
Age
Person’s Relationship to You
(i.e. sister, friend, cousin, etc…)
Monthly
Contribution
Page 5 of 8
0.00
0.00
0.00
0.00
Personal Asset and Debt Chart
A. Complete this chart by listing all of your assets, the value of each, the amount owed on each, and
whose name the asset or debt is under. If more than 15 assets, attach a separate sheet.
Line
Description of Asset and Debt
Thereon
Gross Value
Total Amount
Owed
Net Value
Whose Name is
on the Account?
You, Your
Spouse/Domestic
Partner or Both
1.
$
-
$
=
$
2.
$
-
$
=
$
3.
$
-
$
=
$
4.
$
-
$
=
$
5.
$
-
$
=
$
6.
$
-
$
=
$
7.
$
-
$
=
$
8.
$
-
$
=
$
9.
$
-
$
=
$
10.
$
-
$
=
$
11.
$
-
$
=
$
12.
$
-
$
=
$
13.
$
-
$
=
$
14.
$
-
$
=
$
15.
$
-
$
=
$
Total Value of Assets
(add lines 1-15)
$ - $ =
$
B. Complete this chart by listing all of your unsecured debt, the amount owed on each account, and
whose name the debt is under. If more than 5 unsecured debts, attach a separate sheet.
Line
#
Description of Credit Card or
Other Unsecured Debt
Total Amount
owed
Whose Name is on the Account?
You, Your Spouse/Domestic Partner or Both
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
Total Unsecured Debt (add lines 1-6) $
Page 6 of 8
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
CERTIFICATION
Attorney Information: Complete the following sentences:
1. I (have/have not) ___________________________ retained an attorney for this case.
2. As of the date of today, the attorney has been paid a total of $________ on my behalf.
3. I have a credit with my attorney in the amount of $___________________________.
4. I currently owe my attorney a total of $____________________________________.
5. I owe my prior attorney a total of $ _______________________________________.
IMPORTANT: Read the following paragraphs carefully and initial each one.
______ I swear or affirm under penalty of perjury that I have read and followed all
instructions in completing this Financial Disclosure Form. I understand that, by my signature,
I guarantee the truthfulness of the information on this Form. I also understand that if I
knowingly make false statements I may be subject to punishment, including contempt of
court.
_______ I have attached a copy of my 3 most recent pay stubs to this form.
_______ I have attached a copy of my most recent YTD income statement/P&L
statement to this form, if self-employed.
_______ I have not attached a copy of my pay stubs to this form because I am currently
unemployed.
_______________________________ _________________________
Signature Date
Page 7 of 8
/s/
CERTIFICATE OF SERVICE
I hereby declare under the penalty of perjury of the State of Nevada that the following is true and
correct:
That on (date) ______________________________, service of the General Financial
Disclosure Form was made to the following interested parties in the following manner:
☐ Via 1
st
Class U.S. Mail, postage fully prepaid addressed as follows:
☐ Via Electronic Service, in accordance with the Master Service List, pursuant to NEFCR 9, to:
________________________________________________________
☐ Via Facsimile and/or Email Pursuant to the Consent of Service by Electronic Means on file
herein to: __________________________________________________________
Executed on the _____ day of ________________, 20___.
_____________________________
Signature
Page 8 of 8
/s/
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FDF Attorney for Nevada State Bar No. (Family Law Self Help Center)

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Completed 15 January 2021

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