HO-CHUNK NATION TRIAL COURT
Tribal code
Ask Donna
What actually matters in this document.
Text
1
IN THE
HO-CHUNK NATION TRIAL COURT
2
3
4
STATEMENT OF INCOME, ASSETS, DEBTS
AND LIVING EXPENSES
5
6
Case No(s).: ___ ____ - ____
___ ____ - ____
___ ____ - ____
___ ____ - ____
7
8
9
10
11
12
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:
Name of Person Completing Form (please print):
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.
13
14
15
Number of Household Members:
16
______ Adults
17
18
_____ Children
Employer Information (please print):
19
20
21
22
23
________________________________________
Name
________________________________________
Address
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.
________________________________________
24
City
State
Zip Code
25
(________)_______________________________
Telephone Number
Debtor seeking to establish civil garnishment
exemption pursuant to WIS. STAT. § 812.34(b)-(c).
Other: _________________________________
26
27
28
Statement of Income, Assets, Debts and Living Expenses (2017)
Page 3 of 3
1
2
3
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.)
4
Other income (Pensions, retirement, social security, disability, worker’s
compensation, public assistance)
5
7
Child Support and /or maintenance from prior spouse
Dividends, interest, rents, bonuses
Per Capita Payments or Distributions
Other:
8
Itemized mandatory monthly deductions (Do not include savings
6
Total Monthly Income
or credit union deductions not required by law)
9
10
11
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
12
13
14
15
16
17
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)
18
19
20
21
22
23
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
Total Value of Assets
LONG TERM DEBTS AND MONTHLY EXPENSES
Long Term/Installment Debts
Creditor Name
Balance Owed Monthly Payment
Mortgage Payment (Include property taxes
and insurance if included in payment)
24
25
26
Credit Cards
Automobile Loans
Other
Other
Total Owed
27
28
Statement of Income, Assets, Debts and Living Expenses (2017)
Page 3 of 3
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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:
16
Total Monthly Payments
17
_____________________________________
18
Signature
19
_____________________________________
20
21
Date Signed
SUBSCRIBED AND SWORN TO before me this
day of
, 20______
22
23
at
.
City
State
24
25
Notary Public for
26
My commission expires:
State
27
28
Statement of Income, Assets, Debts and Living Expenses (2017)
Page 3 of 3
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.