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Preliminary Verified Disclosure Statement Kentucky Court of Justice

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					AOC-238       Doc. Code: DSPV
                                                                 EA L TH OF KE
                                                            NW
Rev. 1-11                                                                                        Case No. ____________________




                                                                              NT
                                                      O
                                                     COMM




                                                                                   UCKY
Page 1 of 8                                                              lex
                                                                          et
                                                                       justitia

Commonwealth of Kentucky                                                                         Court _______________________




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                                                                     OF JUS

Court of Justice www.courts.ky.gov
                                            PRELIMINARY	VERIFIED                                 County ______________________
FCRPP 2
                                           DISCLOSURE	STATEMENT                                  Division _____________________


IN RE THE MARRIAGE OF:


________________________________________                                                                   PETITIONER

and

________________________________________                                                                   RESPONDENT



 Petitioner  Respondent submits under oath the following Preliminary Verified Disclosure Statement pursuant to
FCRPP 2 which requires full and prompt disclosure of the following information:

NOTE:	 A	RESPONSE	OF	“SEE	ATTACHED”	IS	NOT	APPROPRIATE	FOR	ANY	PORTION	OF	THIS	STATEMENT.			
	    			ATTACH	DOCUMENTS	REQUESTED	HEREIN	ONLY.

A.	    BACKGROUND	INFORMATION:

1.     Name: ___________________________________               Maiden Name: _________________________
2.     Current Address: _________________________________________________
                         _________________________________________________
                         _________________________________________________
3.     Date of Birth: ______________________________           State of Birth: _________________________
4.     Number of Prior Marriages: _________             How Each Terminated: _________________________
5.     Minor Children From Prior Marriages:
        Name                                             Date of Birth                 Residing With
      ______________________________________________________________________________________
      ______________________________________________________________________________________
      ______________________________________________________________________________________
      ______________________________________________________________________________________
      ______________________________________________________________________________________

6.    Date of Marriage: _________________________   Where License Obtained: ______________________
7.    Date of Separation: _________________________
8.    Children of This Marriage: _________
      Name                                           Date of Birth               Residing With
	     	
      ______________________________________________________________________________________
	     	
      ______________________________________________________________________________________
	     	
      ______________________________________________________________________________________
      ______________________________________________________________________________________
      ______________________________________________________________________________________

9.     Have you attended a divorce education program? ______                              When: ______________________________
10.    Have children attended a children's divorce education program? ______                    When: ________________________	
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11.     Is there an Emergency Protective Order or a Domestic Violence Order in effect regarding these parties? ____
        If so, ATTACH COPY OF ORDER (all pages).
12.     Is there a Petition pending filed by either party for an Emergency Protective Order? ____
        If so, ATTACH COPY OF PETITION (all pages).

B.	     EMPLOYMENT	INFORMATION:
1.      Current Employer: ______________________________________________________________________
               Address: ______________________________________________________________________
                          ______________________________________________________________________

Length of Employment: _________________________
Present Position: ______________________________
How Often Paid: ______________________________
Gross Pay Per Pay Period (including overtime): _________________________
Net Pay Per Pay Period (including overtime): ___________________________

2.      Other/Additional Employer: _______________________________________________________________
               Address: ______________________________________________________________________
                          ______________________________________________________________________

Length of Employment: _________________________
Present Position: ______________________________
How Often Paid: ______________________________
Gross Pay Per Pay Period (including overtime): _________________________
Net Pay Per Pay Period (including overtime): ___________________________

3.      Self-Employment: _______________________________________________________________
        Name of Business: ______________________________________________________________
        Type of Business: _______________________________________________________________
        Address: ______________________________________________________________________
                 ______________________________________________________________________

Length of Self-Employment: _________________________
Present Position: _________________________________
Gross Income Year to Date: _________________________

Ordinary and Necessary Business Expenses Year to Date (list and give totals):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________


Gross Income Last Year from Self-Employment: _________________________

Net Income Last Year from Self-Employment:      _________________________
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ATTACH	COPIES	OF	LAST	THREE	PAY	STUBS	FROM	EACH	EMPLOYER,	LAST	YEAR’S	W-2(S)	AND	LAST	
THREE	STATE	AND	FEDERAL	TAX	RETURNS.

C.	     ADDITIONAL	INCOME	RECEIVED	IN	LAST	12	MONTHS	(Specify	amounts):

1.      Employment Benefits:                                              Amount
        Commissions:                                                      ________________
        Bonuses, incentives, etc.:                                        ________________
        Health Insurance paid by employer                                 ________________
        Housing expenses:                                                 ________________
        Automobile expenses:                                              ________________
        Payment/lease:                                                    ________________
        Mileage:                                                          ________________
        Repairs:                                                          ________________
        Gas:                                                              ________________
        Insurance:                                                        ________________
        Phone/Mobile phone expenses:                                      ________________
        Meals or allowance:                                               ________________
        Club dues:                                                        ________________
        Others (list all and specify amount or value):                    ________________

2.      Interest and Dividends:
        Source
        _________________________________________                         ________________
        _________________________________________                         ________________
        _________________________________________                         ________________

3.      Unemployment:                                                     ________________
4.      Worker’s Compensation:                                            ________________
5.      Social Security/SSI:                                              ________________
6.      TANF:                                                             ________________
7.      Child Support:                                                    ________________
8.      Maintenance:                                                      ________________
9.      Retirement Benefits:                                              ________________
10.     Others (list all and give amounts):                               ________________

        __________________________________________                        ________________

        __________________________________________                        ________________

        __________________________________________                        ________________

        __________________________________________                        ________________

        __________________________________________                        ________________
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D.		    CHILD	SUPPORT	GUIDELINE	INFORMATION:

1.      Medical Insurance:
        Who pays: ________________________________________________________________
        How paid: ________________________________________________________________
        How Much for Child(ren) Only:                                                                         ___________

2.      Dental Insurance:
        Who pays: ________________________________________________________________
        How paid: ________________________________________________________________
        How Much for Child(ren) Only:                                                                         ___________

3.      Child Care Costs:
        Who Provides: ________________________________________________________________
        How Often is Provider Paid: ______________________________________________________
        Name of Provider: ______________________________________________________________
        How Much Paid:                                                                                        ___________
4.      Amount Paid for Court Ordered Child Support for Prior Born Child(ren):                                ___________
5.      Amount Paid for Court Ordered Maintenance for Prior Marriage(s):                                      ___________
6.      Imputed Child Support for Prior Born Child(ren):                                                      ___________
7.      Child Support Received for Child not of this Marriage:                                                ___________
8.      Maintenance Received from Prior Marriage:                                                             ___________

E.	     NONMARITAL	PROPERTY	CLAIMS:
List all property, real or personal, tangible or intangible, of greater than $100.00 in value, which you claim to be either
entirely or partially your nonmarital property.

Item 1--Specify item:
        _____________________________________________________________________

        Fair Market Value at Date of Marriage: _______________________________________
        Debt Balance on Item at Date of Marriage: ____________________________________
        Current Debt Balance on Item: _____________________________________________
        Current Fair Market Value: _________________________________________________
        Basis for your Claim Item is Nonmarital: ______________________________________
        _______________________________________________________________________
        Nonmarital Value of Item:                                                                             ___________

Item 2--Specify item
        _____________________________________________________________________

        Fair Market Value at Date of Marriage: _______________________________________
        Debt Balance on Item at Date of Marriage: ____________________________________
        Current Debt Balance on Item: _____________________________________________
        Current Fair Market Value: _________________________________________________
        Basis for your Claim Item is Nonmarital: ______________________________________
        _______________________________________________________________________
        Nonmarital Value of Item:                                                                             ___________
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F.	     MARITAL	PROPERTY:
1.      Real Property:
            Address                        Fair Market Value   Mortgage(s) Balance   % Interest
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

2.    Vehicles, Motorcycles, Boats, Trailers, Equipment, etc.:
              Year/Make/Model/Type                             Fair Market Value Loan Balance
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3.    Bank Accounts*
             Bank and Type of Account                                        Balance
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

4.      Investments (Stocks, Bonds, Mutual Funds, Stock Options, etc.)*:
               Type and Location of Investment                         # of Shares                  Fair Market Value
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

5.      Life Insurance*:
        Company and Type of Policy                               Cash Surrender
                                                                  Insured         Loan Balance
                                                                    Value
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets, periodic statements from
investments, statements on life insurance, periodic statements from retirement plans, periodic statements reflecting assets
held in name of or on behalf of children, and documents reflecting debts and credit card statements for past 12 months should
be in possession of answering party or answering party’s attorney when this statement is served on the opposing party.

6.    Assets Held in Name of/on Behalf of Children*
             Type & Name of Account                                          Balance or Value
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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7.    Retirement Plans (Pensions, 401(k), Tax Deferred Savings, IRAs, etc.)*:
             Type and Name of Plan                                   Plan Administrator Balance or Value
_______________________________________________________________________________________________
_______________________________________________________________________________________________
8.      Interests In/Ownership of Business:
                 Location of Business,                            % and                     Tax Returns &
                 Business Name & Address                          Type of Business          Financial Documents

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
9.    Household Property in Dispute:
            Item                     Location      Fair Market Value         Loan Balance
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets, periodic statements from
investments, statements on life insurance, periodic statements from retirement plans, periodic statements reflecting assets
held in name of or on behalf of children, and documents reflecting debts and credit card statements for past 12 months should
be in possession of answering party or answering party’s attorney when this statement is served on the opposing party.

10.     Safety Deposit Box?      Yes                      No                     If yes:
                Location                                  Contents                       Value          Date of Last Visit
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

11.    Other Property - (specify item and value):
Jewelry: _________________________________________________________________________________
Furs: ___________________________________________________________________________________
Antiques: ________________________________________________________________________________
Art: _____________________________________________________________________________________
Collections: _______________________________________________________________________________
Country Club Memberships: _________________________________________________________________
Season Tickets: ___________________________________________________________________________
Income Tax Refunds Expected: _______________________________________________________________
Frequent Flyer Miles: _______________________________________________________________________
Accounts Receivables/Loans: ________________________________________________________________
Claims Against Others: ______________________________________________________________________
Accrued Vacation Pay: _______________________________________________________________________
Others: _________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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G.		    DEBTS*:
              Creditor                                    Purpose/Security                Balance            Monthly Pmt.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
* Bank statements, canceled checks, registers, carbon copies of checks, deposit tickets, periodic statements from
investments, statements on life insurance, periodic statements from retirement plans, periodic statements reflecting assets
held in name of or on behalf of children, and documents reflecting debts and credit card statements for past 12 months should
be in possession of answering party or answering party’s attorney when this statement is served on the opposing party.

H.	     MONTHLY	EXPENSES	(Specify	amounts):
                                                          Actual	 	    	     							Anticipated
Rent:
_______________________________________________________________________________________________
Mortgage:
_______________________________________________________________________________________________
Property Tax:
_______________________________________________________________________________________________
Homeowner’s/Renter’s Insurance:
_______________________________________________________________________________________________
House Maintenance:
_______________________________________________________________________________________________
Electric Utilities:
_______________________________________________________________________________________________
Fuel, Oil, Gas Utilities:
_______________________________________________________________________________________________
Telephone:
_______________________________________________________________________________________________
Cellular Phone:
_______________________________________________________________________________________________
Water and Sewer:
_______________________________________________________________________________________________
Garbage Pickup:
_______________________________________________________________________________________________
Yard Expense:
_______________________________________________________________________________________________
Cleaning Service:
_______________________________________________________________________________________________
Child Care/Babysitter:
_______________________________________________________________________________________________
Cable Television:
_______________________________________________________________________________________________
Car Payments/Lease Payments:
_______________________________________________________________________________________________
Auto Gas and Oil:
_______________________________________________________________________________________________
Car Maintenance and Repairs:
_______________________________________________________________________________________________
Car Licenses/Taxes
_______________________________________________________________________________________________
Car Insurance:
_______________________________________________________________________________________________
Religious/Charitable Contributions:
_______________________________________________________________________________________________
Clothing:
_______________________________________________________________________________________________
Uniforms:
_______________________________________________________________________________________________
Dry Cleaners:
_______________________________________________________________________________________________
Entertainment:
_______________________________________________________________________________________________
Gifts:
_______________________________________________________________________________________________
Food:
_______________________________________________________________________________________________
Doctor:
_______________________________________________________________________________________________
Dentist:
_______________________________________________________________________________________________
Orthodontist:
_______________________________________________________________________________________________
Prescriptions Drugs/Medicines:
_______________________________________________________________________________________________
Optometrist/Ophthalmologist/Eyeglasses:
_______________________________________________________________________________________________
Medical/Dental Insurance (not deducted from pay):
_______________________________________________________________________________________________
Life Insurance (not deducted from pay):
_______________________________________________________________________________________________
Disability Insurance (not deducted from pay):
_______________________________________________________________________________________________
Newspaper:
_______________________________________________________________________________________________
Magazine Subscriptions:
_______________________________________________________________________________________________
Veterinarian/Pet Food:
_______________________________________________________________________________________________
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Page 8 of 8                                                             Actual	 	        	       							Anticipated
Professional Dues/Club Memberships:
_______________________________________________________________________________________________
Social Clubs:
_______________________________________________________________________________________________
Barber/Beauty Shop:
_______________________________________________________________________________________________
Tuition/School Expenses:
_______________________________________________________________________________________________
State/Federal/Local Taxes Not Withheld:
_______________________________________________________________________________________________
Child support paid for prior born child
_______________________________________________________________________________________________
Child support for child of marriage
_______________________________________________________________________________________________
Maintenance paid to prior spouse
_______________________________________________________________________________________________
Maintenance paid to current spouse
_______________________________________________________________________________________________
Athletic and Activity Fees (list)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Debt payments (list)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Other Monthly Expenses (list)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
TOTAL	MONTHLY	EXPENSES	                 	 	  	     						$	 	   	      	 0.00 $            0.00
_______________________________________________________________________________________________
 Petitioner  Respondent states that the above information is true and correct to the best of my knowledge and belief,
and that it results from a diligent, good faith effort to ascertain the information sought herein, based upon information
and documents available to me and/or within my possession or control. All documents upon which this information
is based and the documents requested herein have been produced and are currently in the office of my counsel.

                                                                _____________________________________________
                                                                 Petitioner               Respondent

STATE OF KENTUCKY       )
                        ) SCT.
COUNTY OF______________ )
       Subscribed and sworn to before me by _____________________________________, on this the _______ day
of _____________, 2______.

                                                                ___________________________________________
                                                                Notary Public, _____________________
My commission expires: ________________________.


                                                CERTIFICATE	OF	SERVICE

This is to certify that the foregoing Preliminary Verified Disclosure Statement was  mailed  hand-delivered to
counsel for  Petitioner  Respondent on this the _____ day of __________________, _______, and documents
requested and supporting the information set forth herein are currently available at the undersigned’s office or are
in the undersigned’s possession and are available for inspection and copying at the requesting party’s expense.


                                                            ________________________________________________
                                                            ATTORNEY FOR  PETITIONER  RESPONDENT
                                                            or  PETITIONER  RESPONDENT

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