GFDF

Willick Law Group

Marshal S. Willick, Esq.

Nevada Bar No. 2515

3591 E. Bonanza Rd., Ste. 200

Las Vegas, Nevada 89110

(702) 438-4100; Fax (702) 438-5311

email@willicklawgroup.com

Attorney for _____________

District Court, Family Division

Clark County, Nevada

Case No.:
Plaintiff,	Dept. No.:
vs.
Defendant.

GENERAL FINANCIAL DISCLOSURE FORM

A.	Personal Information:
1. What is your full name? (first, middle, last)
2. How old are you?	3. What is your date of birth?
4. What is your highest level of education?

B.	Employment Information:

1. Are you currently employed/self-employed? ( mark one)

No
Yes	If yes, complete the table below. Attach an additional page if needed.

Date of Hire	Employer Name	Job Title	Work Schedule

(days)	Work Schedule

(shift times)

2. Are you disabled? ( mark one)

No
Yes	If yes, what is the level of your disability?
What agency certified you disabled?
What is the nature of your disability?

C.	Prior Employment: If you are unemployed or have been working at your current job for less than two years, completed the following information.
Prior Employer:	Date of Hire:	Date of Termination:
Reason for leaving:
Monthly Personal Income Schedule

A.	Year-to-date Income.

As of the pay period ending	my gross year to date pay is

B.	Determine your Gross Monthly Income.

Hourly Wage

X

=	$0.00

X

52

weeks

=	$0.00

÷

12

Months

=	$0.00
Hourly

wage	Number of hours worked per week	Weekly

Income	Annual

Income	Gross Monthly Income

Annual Salary

$0.00

÷

12

Months

=	$0.00
Annual Income	Gross Monthly Income

C.	Other Sources of Income

Source of Income	Frequency	Amount	12 Month

Average
Annuity or Trust Income:
Bonuses:
Car, Housing, or Other Allowance:
Commissions or Tips:
Net Rental Income:
Overtime Pay:
Pension/Retirement Pay:
Social Security Income (SSI):
Social Security Disability (SSD):
Spousal Support:
Child Support:
Workman's Compensation:
Other:
Total Average Other Income Received	$0.00

Total Average Gross Monthly Income (add totals from B and C above)	$0.00

D.	Monthly Deductions

Type of Deduction	Amount
1.	Court Ordered Child Support (Automatically deducted from paycheck):
2.	Federal Health Savings Plan:
3.	Federal Income Tax:

4.	Amount for you:	$

$0.00
Health Insurance	For Opposing Party:
For your Child(ren):
5.	Life, Disability, or Other Insurance Premiums:
6.	Medicare:
7.	Retirement, Pension, IRA, or 401(k):
8	Savings:
9.	Social Security:
10.	Union Dues:
11.	Other (Type of Deduction):
Total Monthly Deductions:	$0.00

Business/Self-Employment Income and Expense Schedule

A.	Business Income:
What is your average gross (pre-tax) monthly income/revenue from self employment or businesses?

B.	Business Expenses: Attach an additional page if needed.

Type of Business Expense	Frequency	Amount	12 Month Average
Advertising/Political Contributions
Car and Truck used for business
Commissions, wages or fees
Business Entertainment/Travel
Insurance
Legal and Professional
Mortgage or rent
Pension and profit-sharing plans
Repairs and maintenance
Supplies
Taxes and Licenses
Utilities
Other:
Total Average Business Expenses:	$0.00
Personal Expense Schedule (Monthly)

A.	Fill in the table with the amount of money you spend each month on the following expenses and check whether you pay the expense for you, for the other party, or for both of you.

Expense	Monthly Amount I Pay	For Me

Other Party

For Both

Alimony/Spousal Support
Auto Insurance
Car Loan/Lease Payment
Cell Phone
Child Support (if not deducted from pay)
Clothing, Shoes, Etc. . .
Credit Card Payments (minimum due)
Dry Cleaning
Electric
Food (groceries & restaurants)
Fuel
Gas (for home)
Health Insurance (if not deducted from pay)
HOA
Home Insurance (if not included in mortgage)
Home Phone
Internet/Cable & Phone
Lawn Care
Membership Fees
Mortgage/Rent/Lease
Pest Control
Pets
Pool Service
Property Taxes (if not included in mortgage)
Security
Sewer
Student Loans
Unreimbursed Medical Expenses
Water
Other:
Total Monthly Expenses	$0.00
Household Information

A.	Fill in the table below with the name and date of birth of each child, the person the child is living with, and whether the child is from this relationship. Attach a separate sheet if needed.

Child's Name

Child's

DOB	With whom is the child living?	Is this child from this relationship?	Has this child been certified as special needs/disabled?
1.
2.
3.
4.

B.	Fill in the table below with the amount of money you spend each month on the following expenses for each child.

Type of Expense	1st Child	2nd Child	3rd Child	4th Child
Cellular Phone
Child Care
Clothing
Education
Entertainment
Extracurricular & Sports
Health Insurance (if not deducted from pay)
Summer Camp/Programs
Transportation Cost
Unreimbursed Medical Expenses
Vehicle
Other:
Total Monthly Expenses	$0.00	$0.00	$0.00	$0.00

C.	Fill in the table below with the names, ages, and the amount of money contributed by all persons living in the home over the age of 18. If more than four adult household members, attach a separate sheet.

Name	Age	Person's Relationship to You (i.e., sister, friend, cousin, etc.)	Monthly Contribution

Personal Asset and Debt Chart

A.	Complete this chart by listing all of your assets, the value of each, the amount owed on each, and whose name the asset or debt is under. If more than 15 assets, attach a separate sheet.

No.

Description of Asset and Debt Thereon

Gross Value	Total Amount Owed

Net Value	Whose Name is on the Account? You, Your Spouse/Domestic Partner or Both
1.	-	=	$0.00
2.	-	=	$0.00
3.	-	=	$0.00
4.	-	=	$0.00
5.	-	=	$0.00
6.	-	=	$0.00
7.	-	=	$0.00
8.	-	=	$0.00
9.	-	=	$0.00
10.	-	=	$0.00
11.	-	=	$0.00
12.	-	=	$0.00
13.	-	=	$0.00
14.	-	=	$0.00
15.	-	=	$0.00
TOTAL VALUE OF ASSETS	$0.00	-	$0.00	=	$0.00

B.	Complete this chart by listing all of your unsecured debt, the amount owed on each account, and whose name the debt is under. If more than five unsecured debts, attach a separate sheet.

No.	Description of Credit Card or Other

Unsecured Debt	Total Amount Owed	Whose Name is on the Account? You, Your Spouse/Domestic Partner or Both
1.
2.
3.
4.
5.
6.
TOTAL UNSECURED DEBT	$0.00

CERTIFICATION

Attorney Information: Complete the following sentences:

1.	I (have/have not)	retained an attorney for this case.
2.	As of today's date, the attorney has been paid a total of	on my behalf.
3.	I have a credit with my attorney paid in the amount of
4.	I currently owe my attorney a total of
5.	I owe my prior attorney a total of

IMPORTANT: Read the following paragraphs carefully and initial each one.

I swear or affirm under penalty of perjury that I have read and followed all instructions in completing this Financial Disclosure Form. I understand that, by my signature, I guarantee the truthfulness of the information on this Form. I also understand that if I knowingly make false statements I may be subject to punishment, including contempt of court.

I have attached a copy of my three most recent pay stubs to this form.

I have attached a copy of my most recent YTD income statement/P&L statement to this form, if self-employed.

I have not attached a copy of my pay stubs to this form because I am currently unemployed.

Signature	Date

C:\Users\darcy\Downloads\General FDF Template (00257952x7A582) (3).wpd

CERTIFICATE OF SERVICE

Pursuant to NRCP 5(b), I certify that I am an employee of the Willick Law Group and that on this day of June, 2020, I caused the above and foregoing document to be served as follows:

[X]	Pursuant to EDCR 8.05(a), EDCR 8.05(f), NRCP 5(b)(2)(D) and Administrative Order 14-2 captioned "In the Administrative Matter of Mandatory Electronic Service in the Eighth Judicial District Court," by mandatory electronic service through the Eighth Judicial District Court's electronic filing system;

[ ]	by placing same to be deposited for mailing in the United States Mail, in a sealed envelope upon which first class postage was prepaid in Las Vegas, Nevada;

[ ]	pursuant to EDCR 7.26, to be sent via facsimile, by duly executed consent for service by electronic means;

[ ]	by hand delivery with signed Receipt of Copy.

To the litigant(s) listed below at the address, e-mail address, and/or facsimile number indicated below:

An Employee of the Willick Law Group