Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 1 of 7
This form is available in Spanish.
https://www.wicourts.gov/forms1/circuit/index.htm
(Este formulario está disponible en español.)
Enter the name of the
county in which this
case is filed.
STATE OF WISCONSIN, CIRCUIT COURT,
COUNTY
Enter the name of the
Petitioner/Joint
Petitioner A.
Petitioner/Joint Petitioner A
Name (First, Middle and Last)
and
On the far right, check
Petitioner/Joint Petitioner
A or Respondent/Joint
Petitioner B.
Financial Disclosure
Statement of
Petitioner/Joint Petitioner A
Respondent/Joint Petitioner B
Case No.
Enter the name of the
Respondent/Joint
Petitioner B.
Respondent/Joint Petitioner B
Name (First, Middle and Last)
Enter the case number.
This form must be filed with the court within the time period set by the court but no later than 90 DAYS after the service
of the Summons and Petition on the Respondent/Joint Petitioner B or the filing of a Joint Petition. Failure by either
party to complete and file this form or attachments as required will authorize the court to accept the statement of the
other party as the basis for its decisions. Deliberate failure to provide complete disclosure is perjury.
PROOF OF INCOME
Attach a statement reflecting income earned to date for the current year.
Attach most recent W-2 Statement.
GENERAL INFORMATION
Name
Address
Address
City
State Zip
Phone [Day]
Phone [Evening]
Alternative Phone
Social Security Number
Occupation
Employer
Address
Address
City
State Zip
Phone
Fax
Payroll Office
Same as employer
Address
Address
City
State Zip
Phone
Fax
MEMBERS OF YOUR HOUSEHOLD
Enter the name and relationship of all people living in your household. Check yes or no to identify if they
contribute to payment of household expenses.
I live alone.
Name
Relationship
This person helps pay expenses
Yes
No
1.
2.
3.
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 2 of 7
4.
5.
6.
7.
8.
MONTHLY INCOME
Income from wages / salary is received: (check one)
To calculate monthly gross income use the multiplier shown:
weekly -multiply weekly income by 4.33 every other week (bi-weekly) multiply bi-weekly income by 2.17
monthly twice a month-multiply semi-monthly income by 2
MONTHLY GROSS INCOME
1.
Gross monthly income (before taxes and deductions) from salary and wages, including
commissions, allowances and overtime. (See above how to calculate.)
2.
Pensions and retirement funds received
3.
Social Security benefits received
4.
Disability and Unemployment Insurance received
5.
Public Assistance Funds received
6.
Interest and Dividends received
7.
7 Child Support and maintenance (spousal support) received from any prior
marriage/relationship
8.
Rental payments received (from property you rent to others)
9.
Bonuses received
10.
Other sources of income received: (please specify)
11.
12.
13.
Total Gross Income (add lines 1-12)
MONTHLY DEDUCTIONS
14.
Number of tax exemptions claimed
15.
Monthly federal income tax withheld
16.
Monthly state income tax withheld
17.
Social Security
18.
Medicare
19.
Medical insurance
20.
Other insurances
21.
Union or other dues
22.
Retirement or pension fund
23.
Savings plan
24.
Credit union
25.
Child support or spousal support payments
26.
Other deductions: (please specify)
27.
28.
Total Monthly Deductions (add lines 14 – 27)
MONTHLY NET INCOME (subtract line 28 from line 13)
ANTICIPATED MONTHLY EXPENSES
My Monthly Expenses
1.
Rent or mortgage payment (primary residence)
2.
Real Estate Property taxes (residence)
3.
Repairs and maintenance (including maintenance of appliances and furnishings)
4.
Food (include eating out) and household supplies
5.
Utilities (electricity, heat, water, sewage, trash)
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 3 of 7
6.
Telephone (local, long distance & cellular)
7.
Cable and Internet Services
8.
Laundry and dry cleaning
9.
Clothing and shoes
10.
Medical, dental and prescription drug expenses (not covered by insurance)
11.
Insurance (life, health, accident, auto, liability, disability, homeowner’s or renter’s-excluding
insurance that is paid through payroll deductions)
12.
Childcare (babysitting and day care)
13.
Child support or spousal support payments (due to previous marriage or relationship)
(Exclude payments made through payroll deductions)
14.
School expenses (child and adult education)
15.
Entertainment (include clubs, social obligations, travel, recreation)
16.
Incidentals (grooming, tobacco, alcohol, gifts, holidays and special occasions)
17.
Transportation (other than automobile)
18.
Auto payments (loans/leases)
19.
Auto expenses (gas, oil, repairs, maintenance)
20.
Newspapers, magazines, books
21.
Care and maintenance of pets (food, vet, grooming)
22.
Payments to any dependents not living in your home and not included in a category above
(including college age children)
23.
Hobbies
24.
Other taxes than those listed above (exclude payroll deductions)
25.
Other expenses (include expenses of other real properties owned, professional services
such as counseling and tax/legal advice, etc)
Other Monthly installment payments:
26.
Mortgage (other than primary mortgage)
27.
Other vehicle payments
28.
Credit card debt (total minimum monthly payments)
29.
Court ordered obligations
30.
Student loans
31.
Personal loans
TOTAL MONTHLY EXPENSES (Add lines 1-31)
ASSETS: List ALL assets that you own individually and together with the other party without regard to
how they have been or will be divided later
If you do not have assets in an asset category, write “none” under the heading and enter “zero” in the
estimated value column. If you need more space, please attach additional sheets.
A = Joint Petitioner A
B = Joint Petitioner B T = Together
Ownership or Title
Held by
Current
Possession
Amount
Owed
Estimated
Value
Today
Household Items
A
B
T
A
B
T
Household furniture & accessories
Household appliances
Kitchen equipment
China, silver, crystal
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 4 of 7
Jewelry
Clothing
Antiques
Art
Electronic equipment
Sports equipment
Recreational vehicles, boats
Tools
Other:
Other:
Automobiles:
Year, Make, Model
A
B
T
A
B
T
Amount
Owed
Estimated
Value
Today
Life Insurance
Name of Company & Policy #
A
B
T
Beneficiary
Face
Amount
Cash
Value
Today
Business Interests
Name of Business & Address
A
B
T
Type of
Business
% of
Ownership
Value MINUS
Indebtedness
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 5 of 7
Securities: Stocks, Bonds, Mutual Funds,
Commodity Accounts
Name of Company & # of shares
Ownership or Title held by
Value
Today
A = Joint Petitioner A
B = Joint Petitioner B
T = Together
A
B
T
Pension, Retirement Accounts,
Deferred Compensation, 401K Plans, IRAs,
Profit Sharing, etc.
Name of Company & Type of Plan
A
B
T
% Vested
if known
Date of
Valuation
Value
Today
Cash and Deposit Accounts
(Savings and Checking)
Name of Bank or Financial Institution
A
B
T
Type of
Account
Account #
Last 4 digits
Balance
Today
Other Personal Property
Description of Asset
A
B
T
Type of
Property
Value
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 6 of 7
Assets Acquired
Description of Asset
Ownership
Acquired by
Date
Acquired
Value
Today
A = Joint Petitioner A
B = Joint Petitioner B
T = Together
G - Gift
I - Inherited
B - Before Marriage
A
B
T
G
I
B
Real Estate
Parcel 1
Parcel 2
Parcel 3
Type of Property
Address: Street, City, State
Ownership/Title
A B T
A B T
A B T
Current Fair Market Value
Current Mortgage Balance
Other Liens
7.
MEDICAL, HOMEOWNERS/RENTERS, AUTOMOBILE, OTHER INSURANCE
What type of insurance policies do you have?
Name of Company, Group # & Policy #
A
B
T
Type of Insurance
Date Issued
8.
DEBTS: List ALL debts that you owe individually and together with the other party without regard to who
will be responsible for payment later.
If there are additional DEBTS, please attach a separate sheet of paper with the creditor’s name and address, the
type of obligation, who pays (A, B, T) and the current balance.
Creditor’s Name & Address
Type of Obligation
Who Currently
Pays
Monthly
Payment
Current
Balance
A
B
T
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:
FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
Page 7 of 7
9.
DISPOSAL OF ASSETS
Did you dispose of any assets (sold, given away, or destroyed) in the 12 months before the case was filed?
Yes No
If yes, complete chart below:
Property / Asset
Date of Disposal
Fair Market Value on
Date of Disposal
10.
CURRENT LITIGATION
Are you a party in any other lawsuit or litigation? Yes No
If yes, identify the lawsuit or litigation.
11.
BANKRUPTCY
Have you ever filed for bankruptcy? Yes No
If yes, identify the following:
Type of filing
Date of filing
Current status
12.
DECLARATION
I declare under the penalty of perjury that the above, including all attachments, are complete, true, and correct.
Sign and print your
name.
Enter the date on
which you signed
your name.
Note: This signature
does not need to be
notarized.
Signature
Print or Type Name
Address
Email Address Telephone Number
Date State Bar No. (if any)