Free 080-649 - Wisconsin

Dane County Clerk of Circuit Court FINANCIAL DISCLOSURE STATEMENT
This application must be filled out completely ­ PLEASE PRINT. Applications must be received within ten (10) days of conviction. Late applications may require a down payment. A $15 fee is charged for the setting up and monitoring of a deferred payment agreement. The fee must be paid at the time the deferred payment agreement is established.

RETURN THIS FORM WITH $______________________ PAYMENT PLAN FEE AND $______________________ DOWN PAYMENT BY:________________________________
CASE NUMBERS: DATE

BRANCH NO. OR JUDGE

DATE OF CONVICTION

FIRST NAME

M.I.

LAST NAME

ARE YOU KNOWN BY ANY OTHER NAME: WHAT OTHER NAME(S) ARE YOU KNOWN BY?

DATE OF BIRTH

! YES
DRIVER'S LICENSE NO.

! NO
SOCIAL SECURITY NO. (Disclosure of social security number is on a voluntary basis. If disclosed, may be used for collection purposes.)

HOME STREET ADDRESS

CITY, STATE, ZIP CODE

PHONE

NAME OF EMPLOYER/BUSINESS

PHONE

EMPLOYER STREET ADDRESS, CITY, STATE, ZIP

OCCUPATION

NUMBER OF HOURS WORKED PER WEEK MARITAL STATUS:

HOURLY RATE

NUMBER OF LEGAL DEPENDENTS (CHILDREN)

IS YOUR SPOUSE/SIGNIFICANT OTHER EMPLOYED?

!MARRIED !UNMARRIED !SEPARATED
SPOUSE'S OR SIGNIFICANT OTHER'S PLACE OF EMPLOYMENT:

! YES ! YES ! NO

! NO

DO YOU CURRENTLY HAVE A PAYMENT PLAN WITH THE COURT?

1. TOTAL NET INCOME PER MONTH FROM ALL SOURCES (Includes spouse or significant other's income) ................................................... $______________ ALLOWABLE EXPENSES PER MONTH: A. HOUSING (Rent/Mortgage) .......................................... + $______________ B. OTHER COURT ORDERED PAYMENTS ...................... + $______________ (Explain:_____________________________________________________) C. FOOD ................................................................................ $______________ 2. TOTAL ALLOWABLE EXPENSES (Add lines A, B, C & D) .... ($_____________) 3. TOTAL MONTHLY NET ADJUSTED INCOME (Subtract line 2 from line 1) ....... $______________ 4. AMOUNT YOU BELIEVE YOU CAN PAY PER MONTH .................................... $______________
080-649-4 (3/08)