IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS FINANCIAL STATEMENT GROSS INCOME

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1 IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT ST. CLAIR COUNTY, ILLINOIS IN RE THE MARRIAGE OF: and Petitioner No.: Respondent FINANCIAL STATEMENT 1 2 GROSS WAGES OR SALARY ADDITIONAL INCOME (State Source) 3 (add lines 1 and 2) DEDUCTIONS FICA (Social Security Tax) Federal Tax Withholding State Tax Withholding Union Dues Mandatory Retirement Deductions Health & Hospital Insurance Premiums Installment debt payments for medical bills Court-ordered Child Support & Maintenance Case # County & St Necessary Expenses for Production of Income (add lines 4 thru 12) TOTAL DEDUCTIONS (subtract line 13 from line 3) PAY PERIOD TAX FILING STATUS <See Instruction Sheet> PRINT NAME ADDRESS CITY, STATE, ZIP GROSS INCOME TOTAL GROSS INCOME PER MONTH NET INCOME PER MONTH Exemptions Claimed REVISED MARCH 2009

2 HOUSING EXPENSES 17 Rent or Mortgage Payments 18 Homeowner's or Rental Insurance 19 Real Estate Taxes 20 Repairs and Maintenance of Home 21 TOTAL HOUSING 22 (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE 23 (Subtract line 22 from like 21 and enter here) YOUR SHARE Gas Water Electricity Telephone Cable TV and Satelite Fees Trash Service Sewer Gasoline Maintenance and Repairs Registration (plates) Auto Insurance Payment on Auto Loan Life Insurance Premimums (total of line 71; monthly average) Dental Insurance Premiums Other Insurance Premiums (described) UTILITIES TRANSPORTATION TOTAL UTILITIES (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 32 from like 31 and enter here) YOUR SHARE TOTAL TRANSPORTATION (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 40 from like 39 and enter here) YOUR SHARE INSURANCE (NOT Auto or Health) TOTAL INSURANCE (Guidelines: 20% First two Children; 5% each add'l child) CHILDREN'S SHARE (Subtract line 46 from like 45 and enter here) YOUR SHARE

3 48 Food 49 Clothing 50 Medical and Dental Care, Glasses and Drugs 51 Recreation 52 Laundry and Cleaning 53 Hair Care 54 School Expenses and School Lunches 55 Day Care Center or Baby Sitter Charitable and Religious Contributions Other Expenses (attach sheet and enter total here) YOURS (Add lines 23, 33,41, 47 and 48 thru 57) YOUR TOTAL EXPENSES (Add lines 22, 32, 40, 46 and 49 thru 57) CHILDREN'S TOTAL EXPENSES CHILDREN 60 REAL ESTATE MORTGAGE RELATED MARKET EQUITY HOLDER DEBT VALUE 61 MOTOR LOAN RELATED MARKET VEHICLES HOLDER DEBT VALUE EQUITY 62 HOUSEHOLD AND PERSONAL GOODS OVER $300 EACH LOAN HOLDER RELATED DEBT MARKET VALUE EQUITY TOTAL OF GOODS LESS THAN $300 EACH

4 63 RETIREMENT, PENSION, PROFIT SHARING PLANS AND IRA'S COMPANY Begin & End Dates Number of Months Married During Accural Number of Months of Current Accrual Value 64 COMPANY STOCKS, BONDS, MUTUAL FUNDS NUMBER OF SHARES PURCHASE DATE NAME(S) OF OWNER(S) CURRENT VALUE 65 BANK AND SAVINGS AND LOAN ACCOUNTS BANK & ACCT. NO. NAMES CD VALUE SAVINGS CHECKING CASH IN YOUR POSSESSION OR CONTROL LAWSUITS AND WORKMAN'S COMPENSATION CLAIMS-- PENDING OR TO BE FILED CASE COUNTY TYPE OF AMOUNT DEFENDANT NUMBER STATE ACTION CLAIMED 68 MONEY OWED TO YOU RELATIONSHIP DATE LOAN DUE CURRENT DEBTOR TO YOU MADE DATE AMOUNT

5 69 DEBTS OWED TO FRIENDS OR RELATIVES RELATIONSHIP PURPOSE DUE FRIEND OR RELATIVE TO YOU OF DEBT DATE CURRENT BALANCE 70 DEBTS OTHER THAN DEBT RELATED TO ABOVE PROPERTY DATE OF PURPOSE DUE AMOUNT CREDITOR LOAN DATE 71 COMPANY LIFE INSURANCE OWNER INSURED POLICY NUMBER AMOUNT MISCELLANEOUS INFORMATION I SWEAR OR AFFIRM, UNDER PENALTY OF PERJURY, THAT THE FOREGONG INFORMATION IN THIS FINANCIAL STATEMENT IS TRUE AND CORRECT., 20. YOUR SIGNATURE Subscribed and sworn to before me, the undersigned Notary Public, on this day of My Commission expires. Notary Public

6 INSTRUCTIONS FOR FINANCIAL STATEMENT MONTHLY AVERAGES- USE MONTHLY AVERAGES FOR ALL FIGURES. There are 4.33 weeks in an average month. For example, if you have a weekly amount for your income, multiply it by 4.33 t0 convert it to monthly. If you have a figure for two weeks, multiply it by 26 and divide by 12. TRY TO PREDICT THE FUTURE- Based on your current expenses and your future needs do your best to estimate your expenses for the period after the divorce. CHILDREN'S EXPENSES- Fill in items relating to children only if you will have, or expect to have, minor children living with you and only if you have a legal obligation to support them. Do not include expense figured for stepchildren or children from a prior marriage. There are two exceptions. Do include children over 18 if there is a request for educationsl expenses, attach written information from the school relating to the expenses claimed. Also attach written responses to applications for scholarships and grants. The other exception relates to insurance premimums. See instrucions for items 42, 43,44. FAIR MARKET VALUE (FMV)- Fair market value is defined as an amount that a buyer would pay for the item in it's current condition in a normal market such as newspaper want ads, a used car lot, comparable real estate sales, or auction. FMV if a used item is not what you paid for it when it was new, although that price can be used as guidance. NO DUPLICATION OF EXPENSES-Do not duplicate expenses. For example, do not list dental insurance on item 9 and then list it again on item 43. NON-MARITAL PROPERTY- This Financial Statement does not contain any space for lising non-marital property. Ask your attorney about this. Attach a separate page listing marital property and indicate when and how it was acquired and the fair market values INSTRUCTIONS FOR SPECIFIC LINES ATTACHMENTS RELATING TO INCOME- You must attach the following to your Financial Statement: all pages and W-2 forms of your last-filed Federal Income Tax Return; a current pay stub showing your year- to-date earnings and deductions. Include rental income, dividends, interest, business enterprises, social security, AFDC, VA benefits, pensions, annuities, bonuses, commissions, tips and all other sources of income. List the amount of Federal Income Tax withheld or your average estimated tax payments. It should be based on your Tax Filing Status and the number of exemptions you list in line 16. State Income Tax Withholding properly calculated. Union Dues. Monthly average. List Mandatory Retirement Deductions required by law or as a condition of employment. OVER

7 List amount of Dependent and Individual Health/Hospital premiums withheld or paid directly for you and children in your custody. Do not unclude dental insurance unless it is a mandatory part of a health care package. Do not list life, auto, home or rental insurance. List monthly average of payments on debts reltaing to medical treatment necessary for the preservation of life or health. Cosmetic surgery should not be included. Attach itemized bills. List amounts actually paid pursuant to a Court order and include the case number and the County and State where entered. Attach a copy of the order. Do not include amounts in temporary orders. List the average monthly amount of expenses necessary for the production of income. Attach an itemized list and be prepared to justify each item. Indicate whether you are paid weekly, bi-weekly, twice per month or monthly. TAX FILING STATUS. State your filing status (e.g. married or single) and list the total number of Federal Income Tax exemptions that you or your employer used to calculate the federal taxes withheld and that you listed in item 5. Do not list real estate taxes or homeowners insurance premiums if already listed as part of your mortgage payments in line 17. Auto registration expense should be divided by 12 and entered. List total amount of insurance for all vehicles you expect to be awarded. List the amount of premiums paid for you and your children if this marriage even if you do not have custody. Do include premiums for your children who were not born to this marriage. Do not include step-children. Do not include step-children. Do not duplicate premiums liste don lines 9, 18 or 37. Be prepared to itemize the premiums. List actual portion of premium paif for insurance on the life of your children. Do not duplicate this expense elsewhere. Motor Vehicles includes autos, truck, motorcycles, aircraft, boats and mobile homes List items with a current market value of over $300 each. If there are more then eight items, obtain a Personal Property Sheet from your attorney. For the last line, total all of the propertyitems that do not have a value of more than $300. There is no need to describe the individual items with a value of less than $300. BEGIN & END DATES means the dates you started/ended your employment with the sompany or joined the union with which you have a pension or profit sharing plan. Include the account number below the dashed line under the name of the bank. Attach copies of CD's and copies of your most recent savings and checking account statements. Attached copies of notes or any type of document that you have in your possession showing that you owe the amounts listed here. List credit card balances and, bank loans and any other type of dept which is not secured by any property. Attach copies of your most recent credit card statements and loan papers. REVISED MARCH 2009

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