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UCKYOCOMMEA L TH OF KENTNWlexetjustitiaRTCase No.CourtCountyDivisionCUECOq AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVRev. 1-15Page 1 of 10Commonwealth of KentuckyCourt of Justice www.courts.ky.govFCRPP 2 and FCRPP 3OF JUSTIq Preliminary Verified Disclosure Statement*q Final Verified Disclosure Statement*IN RE THE MARRIAGE OF:PETITIONERandRESPONDENTq Petitioner q Respondent submits under oath the following Verified Disclosure Statement pursuant to FCRPP 2 ORFCRPP 3, 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 documentsrequested herein only.I. IDENTIFYING INFORMATION OF BOTH PARTIESPetitioner RespondentName:Name:Street Address:Street Address:City, State, Zip:City, State, Zip:Age:Age: Phone #:Phone #:II. INCOME AND EMPLOYMENT INFORMATION OF BOTH PARTIES (If self-employed name of company andadjusted gross monthly income)Petitioner RespondentEmployer Name:Employer Name:Gross monthly income: Gross monthly income: Other income: Other income: III. MARRIAGE INFORMATIONDate of Marriage:Date of separation:Place of Marriage (city, county & state):
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 2 of 10Case No.IV. CHILDREN’S INFORMATION (If more than 3 children, continue on a separate sheet)A. Minor children born to parties (number )q More CHILDREN attached?NameB. Monthly child care/day care expenses: Cost Current AgePaid byC. Monthly medical, dental and vision insurance for children: Cost Paid byD. Either party court-ordered to pay child support for a child born before the children born of this marriage? q Yes q NoPaying partyAmount: Children: (List names and ages)V. SUMMARY OF ASSETS & DEBTSA. REAL ESTATE (If more than 2 properties, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Property 1:Address:1st Mortgage Company:1st Mortgage Payoff Amount:2nd Mortgage Company or Home Equity Loan:2nd Mortgage or Home Equity Loan Payoff Amount:Fair Market Value:Valuation Date:Equity:Property 2:Address:1st Mortgage Company:1st Mortgage Payoff Amount:2nd Mortgage Company or Home Equity Loan:2nd Mortgage or Home Equity Loan Payoff Amount:Fair Market Value:Valuation Date:More REAL ESTATE attached? q Yes q NoEquity:Total Real Estate Equity:
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 3 of 10Case No.B. VEHICLES - Automobiles, Motorcycles, Boats, Trucks, Motor Homes, etc. (If more than 3 vehicles, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Vehicle 1:Primary Driver: Year, Make & Model:NADA Value:Valuation Date:Debt Owed:Lien Holder: Equity:Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment:Lease Term Ends:Vehicle 2:Primary Driver: Year, Make & Model:NADA Value:Valuation Date:Debt Owed:Lien Holder: Equity:Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment:Lease Term Ends:Vehicle 3:Primary Driver: Year, Make & Model:NADA Value:Valuation Date:Debt Owed:Lien Holder: Equity:Is this a leased vehicle? q Yes q No If yes, please complete the following: Monthly Payment:Lease Term Ends:More VEHICLES attached? q Yes q NoTotal Vehicle Equity:C. BANK ACCOUNTS – Checking, Savings, CDs, Money Market accounts, etc. (If more than 3 accounts, continue ona separate sheet) (Do not list account numbers)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Owner(s)More BANK ACCOUNTS attached?Institution Name[ NO ACCOUNT NUMBERS]Type of Accountq Yes q NoValuation DateBalanceTotal Current Balances:D. STOCKS, BONDS, PORTFOLIOS, MUTUAL FUNDS, ETC. (If more than 3, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Institution NameMore INVESTMENTS attached?Stock/Portfolio Nameq Yesq NoValuation DateTotal Current Values:Current Value
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 4 of 10Case No.E. RETIREMENT BENEFITS – IRA, Keogh, 401(K), 403(b), Pension, etc. (If more than 3, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.ParticipantPlan NameMore RETIREMENT BENEFITS attached?Contrib/Non Vested/Nonq Yes q NoPay Status?Valuation DateBalanceTotal Retirement Benefits Values:Have any loans been taken out against any of these Retirement Benefits? q Yes q NoIf so, describe:F. LIFE INSURANCE (If more than 3 policies, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Policy 1:Company:Party Insured:Beneficiary: Term/Whole:Policy #: Valuation Date: Cash Surrender Value:Policy 2:Company:Party Insured:Beneficiary: Term/Whole:Policy #: Valuation Date: Cash Surrender Value:Policy 3:Company:Party Insured:Beneficiary: Term/Whole:Policy #: Valuation Date: Cash Surrender Value:More LIFE INSURANCE attached? q Yes q NoTotal Cash Value:G. BUSINESS INTERESTS (If more than 3 businesses, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Name of Business & Owner:Percentage of Ownership:Type of Business:Corporation, Sole Proprietorship, Partnership, Etc.:Valuation Date: Business Loan(s) Balance: Value of Interest:Name of Business & Owner:Percentage of Ownership:Type of Business:Corporation, Sole Proprietorship, Partnership, Etc.:Valuation Date: Business Loan(s) Balance: Value of Interest:
q AOC-238 Doc. Code DSPVRev. 1-15Page 5 of 10q AOC-239 Doc. Code DSFVDisclosure ofCase No.Name of Business & Owner:Percentage of Ownership:Type of Business:Corporation, Sole Proprietorship, Partnership, Etc.:Valuation Date: Business Loan(s) Balance: Value of Interest:More BUSINESS INTERESTS attached? q Yes q NoTotal Values:H. HOUSEHOLD GOODS:Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Agreed Division?q Yesq No, but not expected to be in dispute.q No, but dispute anticipated (Suggested appraiser: )Attached is a list of the disputed household itemsI. OTHER ASSETS – Cash, Travelers Checks, Debts Others Owe You, Copyrights, Trademarks, Pets or Animals,Jewelry, Collectibles, Tools, Inventions, Other “Liquid Assets,” etc. (If more than 5 items, continue on a separate sheet)Are you making a non-marital claim? q Yes q No If yes, you must comply with Section IX below.Item 1:Item Description:Who Holds Possession:Valuation Date:Fair Market Value: Amount Owed: Net Value or Equity:Item 2:Item Description:Who Holds Possession:Valuation Date:Fair Market Value: Amount Owed: Net Value or Equity:Item 3:Item Description:Who Holds Possession:Valuation Date:Fair Market Value: Amount Owed: Net Value or Equity:Item 4:Item Description:Who Holds Possession:Valuation Date:Fair Market Value: Amount Owed: Net Value or Equity:Item 5:Item Description:Who Holds Possession:Valuation Date:Fair Market Value: Amount Owed: Net Value or Equity:More OTHER ASSETS attached? q Yes q NoTotal Values:
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 6 of 10Case No.VI. OTHER DEBTS NOT PREVIOUSLY LISTED (Do not list account numbers) Includes credit card balances, creditunion loans, signature loans and other unsecured debt. (If more than 5 debts, continue on a separate sheet)Creditor 1:Creditor:Party Named on Debt:Premarital Account?Valuation Date: Monthly Payment: Total Balance:Creditor 2:Creditor:Party Named on Debt:Premarital Account?Valuation Date: Monthly Payment: Total Balance:Creditor 3:Creditor:Party Named on Debt:Premarital Account?Valuation Date: Monthly Payment: Total Balance:Creditor 4:Creditor:Party Named on Debt:Premarital Account?Valuation Date: Monthly Payment: Total Balance:Creditor 5:Creditor:Party Named on Debt:Premarital Account?Valuation Date: Monthly Payment: Total Balance:More DEBTS attached? q Yes q NoTotal Debt Balances:VII. EXPECTED POST-DIVORCE LIVING EXPENSES SCHEDULE (Do not include debts)Not necessary if maintenance or child support are not being claimed.Do the parties’ combined gross incomes exceed 15,000 per month?q YesIf NO, do not include children’s personal expenses below.If YES, list children’s personal expenses such as private school tuition, tutors,camps, activity fees, clothing, etc. on a separate sheet.q Attachedq No
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 7 of 10Case No.A. COMMON EXPENSES FOR FAMILY(Party and any children of the marriage)B. YOUR PERSONAL EXPENSES(not including any children’s expenses)FOOD/GROCERIES FOR FAMILY(Non-entertainment)Church and charitable donationsHOUSINGCosmetics, hygiene & toiletriesCableDisability insuranceGarbage collectionDry cleaning & laundryElectric, gas, propane & oil utilitiesEntertainment, includingrestaurants & moviesHome maintenance & repairsHair care (barber, salon, etc.)Homeowner’s insuranceInternet accessHousehold suppliesLife insurance (whole life or term)Maid serviceManicures & pedicuresProperty taxesNewspapers, magazines & booksRent or 1st mortgageProfessional dues or uniforms2nd mortgage/home equity loanTelephoneClothingSports, exercise, hobbies, crafts, etc.Travel (monthly average)Mobile phoneMEDICALVet/pet suppliesDental (including orthodontics)Yard expense/maintenanceEyeglasses, contacts & hearing aids,exams and testingWater/sewageInsurance (hospitalization)TRANSPORTATIONGas and oilMedical doctor(s)Liability insurancePrescription medicationLicense/taxes/tagOTHER PERSONAL EXPENSES (list):Payment/loanRepairs/maintenanceOther – bus, taxi, tolls & parkingOTHER FAMILY EXPENSES (list):Sub-total from attached other personalexpenses, if needed q AttachedSUBTOTAL FROM COLUMN B 0.00SUBTOTAL FROM COLUMN A 0.00Sub-total from attached other familyexpenses, if needed q AttachedSUBTOTAL FROM CHILDREN’SEXPENSE LIST ATTACHMENTSUBTOTAL (Column A)GRAND TOTALof column a, b, and 0.00attachments 0.00
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 8 of 10Case No.VIII. OTHERA.Special needs of parties:B.Bankruptcy:C.Lawsuits:IX. REQUIRED ATTACHMENTS (to be sent ONLY to opposing party or opposing counsel and not filed with the Court):To complete this section, you must attach all of the following documents and/or provide the requested information on aseparate sheet and attach to this form. In the spaces provided, mark as follows:“A” to indicate that the requested document/information is attached.“U” to indicate that the requested document/information is unavailable (Provide explanation on a separate page)“N/A” if not applicableA.PERSONAL INFORMATION OF BOTH PARTIESB.INCOME AND EMPLOYMENT OF BOTH PARTIESA, U, N/AItem #1.Three (3) most recent paycheck stubs2.Federal Income Tax Return for the last year filed3.State Income Tax Return for the last year filed4.Documentation of all other income for the past 48 months, including source of income andamount of income received year-to-dateC. CHILDRENA, U, N/AItem #1.Verification of work-related child care expenses2.Verification of cost of health/dental insurance for children’s portion (e.g. difference betweencost of single and family plan)D. ASSET SCHEDULESA, U, N/AItem #1.Most recent statement of each bank account2.Most recent brokerage statement or documentation of purchase and/or value for each investment3.Explanation of source of cash holdings, location and amount of cash4.For each piece of real estate, copy of deed, documentation of all indebtedness (i.e., mortgage,home equity loan, liens, etc.) including unpaid balance and payoff (with date payoff amountobtained) for each debt, and current tax assessment5.Declaration page of life insurance policies and documentation of cash surrender
q AOC-238 Doc. Code DSPVq AOC-239 Doc. Code DSFVDisclosure ofRev. 1-15Page 9 of 10A, U, N/ACase No.Item #6.Documentation of benefits accrued in pension, profit sharing, 401(k) or other retirement plans,including most recent statements of each such plan and the name, address and phone numberof plan administrator7.For each vehicle, provide amount of payoff of any indebtedness (including date payoff amountobtained) and copy of title8.For each business interest, list name of business, extent of interest or title in business (i.e.owner, shareholder, partner, etc.), provide a copy of last income tax return filed by businessand documentation of income earned (or portion received) through business during lasttwenty-four (24) months9.Provide a list describing any other assets you have an interest in, including any documentationas to the value of the non-marital interest, date asset was acquired, and source of non-maritalinterest (trace and document non-marital funds used to acquire each asset)10.NON-MARITAL INTEREST. For each asset in which you claim a non-marital interest, providethe basis and approximate value of non-marital claim. Documentation tracing any non-maritalasset shall be produced if available, and if not currently available, shall be produced whenavailable, or as specified by separate court orderE. DEBT SCHEDULEA, U, N/AItem #1.For each debt, provide the last statement or documentation of unpaid balance, or explainwhy documentation is not available2.For each debt designated as “non-marital”, list the party you think should assume responsibilityfor said debt and whyVERIFICATIONI, , declare under penalty of perjury that the informationcontained herein, including the information provided on any schedules and attachments, is true and accurate to the bestof my knowledge, information and belief. Further, I acknowledge that I have read the foregoing instructions and havefollowed those instructions to the best of my ability.q Petitionerq Respondent{check one}
q AOC-238 Doc. Code DSPVq AOC 239 Doc. Code DSFVDisclosure ofRev. 1-15Page 10 of 10STATE OF)) SSCOUNTY OF)Case No.Subscribed and sworn before me by , this day of ,.My commission expires:NOTARY PUBLIC/TITLECERTIFICATE OF SERVICEI HEREBY CERTIFY that a copy of this Verified Disclosure Statement (with schedules and attachments) wasserved by q mail, postage prepaid, or q hand-delivery, or q electronic means, in accordance with Kentucky Rule of CivilProcedure (CR) 5.02, on (name)at (address) ,this the day of , .Signatureq Attorney for Petitioner q Attorney for Respondentq Petitioner q RespondentAddress:Phone: ()Fax: (Email:)*NOTEWhen this form is utilized as an AOC-238, Preliminary Verified Disclosure Statement, unless otherwise ordered bythe Court or required by Local Rule, this form is NOT to be filed with the Court. FCRPP 2(3). However, the entireform and all attachments are to be exchanged between the parties within 45 days of service of the petition on therespondent, and objections thereto shall be exchanged within 20 days thereafter.When this form is utilized as an AOC-239, Final Verified Disclosure Statement, pursuant to FCRPP 3(3), this formis to be filed with the Court no later than 5 days prior to the trial if property matters are in dispute at that trial.However, the parties may file an AOC-239.2, Affidavit of No Change in Circumstances, since the completion of theAOC-238, Preliminary Verified Disclosure Statement, IF one was filed with the Court. A copy of the Final VerifiedDisclosure Statement or the Affidavit, together with any supporting documentation, shall be provided to theopposing party 15 days prior to trial unless otherwise ordered by the Court.PrintReset Form
B. YOUR PERSONAL EXPENSES (not including any children's expenses) Church and charitable donations Clothing Cosmetics, hygiene & toiletries Disability insurance Dry cleaning & laundry Entertainment, including restaurants & movies Hair care (barber, salon, etc.) Internet access Life insurance (whole life or term) Manicures & pedicures
