Client Worksheet Free Consultation Contact Us Now Call us now 920-472-4600 Client Worksheet Contact InformationNamePhoneEmailGeneral InformationCourt InformationCase NumberCourt NameCourt CircuitCourt LocationNotesNotesNotesNotesPreviousNextGeneral InformationPetitioner/Plaintiff NameRespondent/Defendant NameChildren in this relationshipYes / NoYesNoCase NameNotesNotesNotesNotes Child from this Relationship Choose who the child resides with the mostFatherMotherOther Other Child in Household NotesPreviousNextGeneral InformationInformation about the parties submitting the financial affidavitSubmitter NameSubmitter AddressSubmitter CitySubmitter StateSubmitter ZipNotesSubmitter Telephone NumberSubmitter Fax NumberSubmitter EmailSubmitter RoleSelect the role of the submitterPlaintiffDefendantSubmitter NameMarriage DateMarriage Dissolution DateSubmitter Date of BirthSubmitter Soc Sec NoNotesNotesNotesNotesNotesNotesNotesNotesNotesSubmitter Employed?Choose the employment statusEmployedUnemployedRetiredNotesUnemployment ExplanationEfforts to find workExpected Employment DateExpected Employment Pay- Pay Period -MonthlyWeeklyBi-WeeklySemi-monthyAnnually Submitter's Job Details Occupation Employer Name Employer Address Employer City, State, Zip Employer Telephone Pay Rate Pay Period Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually Notes Submitter's Retired Job Employer Name Employer Address Employer City, State, Zip Employer Telephone NotesPreviousNextIncome DetailsGross Salary or WagesChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyBonusChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyCommissionChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyAllowancesChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyOvertimeChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyTipsChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyBusiness/Self-employmentChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyDisabilityChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyWorker's CompensationChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyUnemploymentChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyPensionChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyOther RetirementChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyAnnuityChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallySocial SecurityChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyInterestChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyDividendsChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNet Rental IncomeChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyRoyaltiesChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyTrustChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyEstateChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyAlimony - This caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyAlimony - Other caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyChild Support - This caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyChild Support - Other caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Income(s) Description Value Period Type Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually OtherOtherSalarySelf-Employment IncomePartnershipCommissionsTipsBonusInterestDividendsPension & RetirementAnnuitySocial Security RetirementReimbursed ExpensesRentalProperty Sales GainsRoyaltyTrustEstateDisability/SSIUnemploymentWorkers CompPublic Aid/Food StampsAlimony ReceivedFellowships/Stipends PreviousNextDeductionsTax Filing Status- Select -SingleHead of HouseholdMarried, JointMarried, SeparateNotesNumber of Dependents ClaimedNotesFederal TaxChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesState TaxChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesLocal TaxChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesFICA or Self-Employment TaxChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMedicare TaxChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMandatory Union DuesChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMandatory RetirementChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesHealth Insurance PremiumChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesFor the below sections, check with your state or attorney before entering a value here. You may need to enter it in the Expense section instead. Do not enter in both Deduction and Expense.Alimony - This caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAlimony - Other caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChild Support - This caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChild Support - Other caseChoose the period- Select -MonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotes Other Deductions(s) Description Value Period Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually PreviousNextAssets - Property Home(s) Address City, State, Zip Value (Est.) Mortgage/Home Equity Loans Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Other Property Address City, State, Zip Value (Est.) Mortgage/Home Equity Loans Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Auto, Boats, RVs, Motor Bikes, etc. Year Make Model Value (Est.) Loan Balance Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Other Personal Property Description Value (Est.) Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife PreviousNextAssets - Financial Cash on Hand Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Bank Account Description Type Value Title Marital Notes Choose the type of bank accountOtherSavingsCheckingCDMoney Market Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Stocks Description Ticker Symbol Date of Valuation Shares Price per Share Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Bond Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Mutual Fund Description Ticker Symbol Date of Valuation Shares Price per Share Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Life Insurance Company Name Name of Insurance Amount Cash Value Loan Amount Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Retirement/Deferred Compensation Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Other Financial Asset(s) Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife PreviousNextAssets - Miscellaneous Business Interests Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Other Asset(s) Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Contingent asset Description Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife Asset transferred in the past year Description Recipient of Asset Value Title Marital Notes Choose ownership of titleJointHusbandWife Choose Marital/JointYesNo - HusbandNo - Wife PreviousNextExpenses - HouseholdMortgageEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesRentEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesHome Equity LoanEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesReal Estate TaxEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesCondo Fees / AssessmentsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesHome / Rental InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesNatural GasEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesElectricityEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesTelephoneEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesCable / Satellite TVEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesWaterEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesSewerEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesTrashEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther UtilitiesEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesLawn CareEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMaid / CleaningEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesLaundry / Dry CleaningEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesFood / GroceriesEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMeals OutEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Household Expense(s) Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo PreviousNextExpenses - Transportation ExpensesGas / OilEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAuto RepairEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAuto Loan PaymentsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAuto Tags / EmissionsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAuto Rentals / ReplacementsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesTollsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesParkingEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesPublic / Other TransportationEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesCar InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Transportation Expense(s) Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo PreviousNextExpenses - PersonalPersonal ClothingEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesPersonal GroomingEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMedical InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesDental InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesTerm Life InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesWhole Life InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesUnreimbursed Medical / PrescriptionsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesUnreimbursed DentalEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesCosmetics, Toiletries, SundriesEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesMandatory RetirementEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesVoluntary RetirementEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesPersonal EducationEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesEntertainmentEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesClub DuesEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesSports / HobbiesEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesVacationEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesPeriodicals / Books / Tapes / CDsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesGiftsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesReligiousEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Personal Expenses Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo PreviousNextExpenses - Child Children's Nursery, Babysitting, DaycareEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's ClothingEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's Tuition / BooksEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's Lessons / Clubs / CampsEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's EntertainmentEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's Life InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's Medical / Dental InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChildren's Unreimbursed Medical / Dental InsuranceEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Child Expense(s) Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo Child From Other Relationship Expense(s) Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo PreviousNextExpenses - MiscellaneousFor the below sections, Check with your state or attorney before entering a value here. You may need to enter it in the Deductions section instead. Do not enter in both Deduction and Expense.Alimony - This caseEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesAlimony - Other caseEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChild Support - This caseEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesChild Support - Other caseEstimated? Yes NoChoose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnuallyNotesOther Miscellaneous Expense(s) Description Payment Amount Pay Period Estimated or not? Notes Choose the periodMonthlyWeeklyBi-WeeklySemi-monthlyAnnually SelectYesNo Comments I consent to have this website store my submitted information so Culp Law Firm can review my information. Previous Submit Form
