INSTRUCTIONS FOR STATEMENT OF INCOME, ASSETS,
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INSTRUCTIONS FOR STATEMENT OF INCOME, ASSETS,
DEBTS, AND LIVING EXPENSES
These instructions are only intended to provide information on how to fill out this form. It is
not intended to substitute legal advice. There may be additional documents and procedures
for your particular type of civil action. If you have any legal questions regarding the specific
facts of your case, please consult with an attorney.
For other questions, you may contact the Trial Court at (715) 284-2722. In addition, copies of
the applicable law can be found on the Nation’s website located at https://hochunknation.com/home/government/legislative/ho-chunk-nation-laws/ or by contacting the HoChunk Nation Legislature at (715) 284-9343 or (800) 294-9343.
Do not include these instruction sheets when you file the completed form.
Statement of Income, Assets, Debts, and Living Expenses: A Statement of Income, Assets, Debts,
and Living Expenses provides the court with a summary of your financial situation.
Instructions:
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Page 1, Lines 3-9: Enter the case number, if known. Otherwise, leave this section blank
and the Court will fill it in.
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Page 1 (Left Side), Lines 12-14: Enter your full, legal name on the line provided.
•
Page 1 (Left Side), Lines 15-18: Enter the number of household members residing with
you.
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Page 1 (Left Side), Lines 19-27: Enter your employer’s information.
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Page 1 (Right Side), Lines 12-27: Check the corresponding box that applies to your
situation.
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Page 2, Lines 1-7: Provide details about your monthly household income i.e. for each
item listed, state how much each household member earns per month. Estimate to
the best of your knowledge if exact figures are unknown. Attach additional statements
for each household member if necessary.
•
Page 2, Lines 8-11: Provide details about your mandatory monthly household
deductions i.e. for each item listed, state how much each household member has
deducted from their monthly income. Estimate to the best of your knowledge if exact
figures are unknown. Attach additional statements for each household member if
necessary.
Instructions for Statement of Income, Assets, Debts, and Living Expenses (Nov. 2019)
Page 1 of 2
INSTRUCTIONS FOR STATEMENT OF INCOME, ASSETS,
DEBTS, AND LIVING EXPENSES
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Page 2, Line 12: Enter your net monthly household income i.e. total monthly income
minus total mandatory monthly deductions.
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Page 2, Lines 13-20: Provide details about the assets you possess. For each asset,
provide a description and estimate its value.
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Page 2, Line 21: Enter the total value of your assets.
•
Page 2, Lines 22-26: Provide details about your long term debts and monthly
expenses. For each long term debt or monthly expense, state the creditor’s name,
balance owed, and the monthly payment. Estimate to the best of your knowledge if
exact figures are unknown.
•
Page 2, Line 27: Enter the total amount owed i.e. long term debts plus monthly
expenses.
•
Page 3, Lines 1-15: Provide details about your other monthly debts and expenses i.e.
state how much you spend per month on each item listed. Estimate to the best of
your knowledge if exact figures are unknown.
•
Page 3, Line 16: Enter your total monthly payments i.e. add up all your other monthly
debts and expenses.
•
Page 3, Lines 17-28: After you complete the form, you must sign and date the form
and have it notarized.
Instructions for Statement of Income, Assets, Debts, and Living Expenses (Nov. 2019)
Page 2 of 2
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IN THE
HO-CHUNK NATION TRIAL COURT
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STATEMENT OF INCOME, ASSETS, DEBTS
AND LIVING EXPENSES
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Case No(s).: ___ ____ - ____
___ ____ - ____
___ ____ - ____
___ ____ - ____
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Under penalty of perjury, I state that the following information on this financial statement is
true, accurate and complete to the best of my knowledge:
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Name of Person Completing Form (please print):
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________________________________________
Number of Household Members:
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______ Adults
_____ Children
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Employer Information (please print):
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________________________________________
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Name
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________________________________________
Address
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________________________________________
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City
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(________)_______________________________
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State
Zip Code
Telephone Number
I am completing this form as a:
Parent, child, or guardian seeking legal
representation pursuant to the HOCAK NATION
CHILDREN AND FAMILY ACT, 4 HCC § 3.24c.
Parent or guardian required to reimburse the HoChunk Nation for child placement assistance or pay
child support to an appointed guardian pursuant to the
HOCAK NATION CHILDREN AND FAMILY ACT, 4 HCC
§ 3.81, 3.114 .
Spouse subject to a divorce proceedings in which
either party seeks a division of assets and debts or
spousal maintenance. DIVORCE AND CUSTODY
ORDINANCE, 4 HCC § 9.8c-d.
Parent, guardian, or adult beneficiary requesting
the release of Children’s/Incompetent’s Trust Fund
(CTF/ITF) monies. PER CAPITA DISTRIBUTION
ORDINANCE, 2 HCC § 12.8c.
Debtor seeking to establish civil garnishment
exemption pursuant to WIS. STAT. § 812.34(b)-(c).
Other: _________________________________
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Statement of Income, Assets, Debts & Living Expenses (2019)
Page 1 of 3
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STATEMENT OF MONTHLY HOUSEHOLD INCOME
(if there are insufficient columns for all household members, attach additional
schedules)
Salary and wages (if weekly or biweekly, compute as a monthly
figure.)
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Other income (Pensions, retirement, social security, disability, worker’s
compensation, public assistance)
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7
Child Support and /or maintenance from prior spouse
Dividends, interest, rents, bonuses
Per Capita Payments or Distributions
Other:
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Itemized mandatory monthly deductions (Do not include savings
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Total Monthly Income
or credit union deductions not required by law)
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Federal and state income taxes, social security, Medicare
Union or other dues
Retirement and pension funds
Other mandatory monthly deductions
Total Mandatory Monthly Deductions
Net Monthly Income
STATEMENT OF ASSETS
Asset
Description
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Fair Market /
Cash Value
Real Estate (List kind of property and location)
Other real estate (List kind of property and location)
Vehicle (Give year and make)
Other Vehicles (Give year and make)
Checking account (Give name of financial
institution)
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Savings account (Give name of financial institution)
IRA/Pension/Profit Sharing
Life Insurance with cash value
Stocks/Bonds/Certificates of Deposit
Other assets valued over $200
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Total Value of Assets
LONG TERM DEBTS AND MONTHLY EXPENSES
Long Term/Installment Debts
Creditor Name
Balance Owed Monthly Payment
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Mortgage Payment (Include property taxes
and insurance if included in payment)
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Credit Cards
Automobile Loans
Other
Other
Total Owed
Statement of Income, Assets, Debts & Living Expenses (2019)
Page 2 of 3
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Other Monthly Debts/Expenses
Rent (Do not duplicate mortgage payment above.)
Repairs/maintenance on home
Food
Electricity/water/heat
Telephone
Laundry and dry cleaning
Child support (paid for children not in your home)
Maintenance (paid to an ex-spouse)
Clothing and shoes
Health insurance premiums
Medical/dental/drug expenses not covered by insurance
Life insurance premiums
Other insurance premiums (specify):
Child care
Cable TV
Transportation costs (oil/gas/commuting)
School
Entertainment/incidentals/newspapers/books/periodicals
Hobbies
Other:
Other:
Other:
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Total Monthly Payments
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_____________________________________
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Signature
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_____________________________________
Date Signed
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SUBSCRIBED AND SWORN TO before me this
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at
day of
, 20______
.
City
State
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Notary Public for
State
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My commission expires:
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Statement of Income, Assets, Debts & Living Expenses (2019)
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This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.