N.D. R. Ct. XI app D
STATE OF NORTH DAKOTA
IN DISTRICT COURT
_____ JUDICIAL DISTRICT
COUNTY OF __________________
CIVIL NO.___________________
| A. B., Plaintiff | ) | |
| ) | RULE 8.3, NDROC, | |
| vs. | ) | PRETRIAL CONFERENCE |
| ) | STATEMENT | |
| C. D., Defendant | ) |
1. PERSONAL INFORMATION
Full Name____________
Present Mailing Address ____________
Employer____________
Street Address ____________
City, State, Zip ____________
Birth date and present age ___________
Marriage Date____________
Separation Date (Different Residences) ____________
Date(s) of Temporary Order(s), if any ____________
Minor children born to this marriage or who will be affected by this legal action:
INITIALS____________
BIRTH YEAR____________
AGE____________
LIVING WITH____________
Is the wife pregnant? _____ Yes _____ No.
If yes, the due date is ____________.
Are parenting rights and responsibilities of any child contested? ____yes ____No.
If yes, attach your proposed parenting plan for each child.
2. EMPLOYMENT/INCOME
Provide the following data for each employer.
| HUSBAND | WIFE | |||
| A) | Name of Employer | ____________ | ____________ | |
| Length of Employment | ____________ | ____________ | ||
| Income Per Month: | ||||
| (1) | Gross income | ____________ | ____________ | |
| Guideline deductions: | ____________ | ____________ | ||
| Federal Income Tax | ____________ | ____________ | ||
| State Income Tax | ____________ | ____________ | ||
| FICA/Medicare | ____________ | ____________ | ||
| Health Insurance for children | ____________ | ____________ | ||
| Union Dues | ____________ | ____________ | ||
| Mandatory Retirement | ____________ | ____________ | ||
| (2) | Subtotal of Guideline Deductions | ____________ | ____________ | |
| (3) | Net Income (Line 1-Line 2) | ____________ | ____________ | |
| Other guideline considerations | ||||
| Specify: | ____________ | ____________ | ||
| (4) | Subtotal of Other Deductions | ____________ | ____________ | |
| (5) | NET TAKE HOME PAY | ____________ | ____________ | |
| (Line 3-Line 4) Tax withholding figures above are based upon Married or Single tax- payer with # of exemptions: (Example M-4 or S-2) | ||||
| B) | Employment benefits: | ____________ | ____________ | |
| Identify all benefits in addition to wages including bonuses paid or due, automobile or travel expense reimbursement, other per diem compensation, memberships paid by the employer or in kind benefits. | ||||
| C) | Other Income: | |||
| (1) | Public Assistance Per Month (AFDC/GA) | ____________ | ____________ | |
| (2) | Social Security, Including ChildBenefits, PerMonth | ____________ | ____________ | |
| (3) | Unemployment/ Workers Comp Per Month | ____________ | ____________ | |
| (4) | Interest Income Per Month | ____________ | ____________ | |
| (5) | Dividend Income Per Month | ____________ | ____________ | |
| (6) | Other Income Per Month | ____________ | ____________ | |
| (7) | Last Year's Tax Refunds | |||
| Federal | ____________ | ____________ | ||
| State | ____________ | ____________ | ||
3. CHILD SUPPORT/SPOUSAL SUPPORT
A) Child or spousal support established in separate proceeding:
(1) Is either party entitled to child or spousal support from a separate proceeding? Yes____ No____.
If yes, for each party entitled to child or spousal support, specify the amount: $____________.
(2) Is either party required to pay child or spousal support from a separate proceeding? Yes____ No____.
If yes, for each party required to pay child or spousal support, specify the amount: $________.
B) Child or spousal support established by temporary order in this proceeding:
(1) Is either party required to pay child or spousal support under a temporary order in this proceeding? Yes____ No____.
If yes, specify the amount: Child Support $___________. Spousal Support $_________.
(2) Is any arrearage claimed under an existing temporary order? Yes____ No____.
If yes, specify the amount: Child Support $_________. Spousal Support $_________.
4. LIVING EXPENSES
Specify the amount of your total monthly expenses $__________; and attach an itemized list of your monthly expenses.
5.REAL PROPERTY: (For Each Parcel of Property)
1. Description of Property_______________________
(a) In Possession of_______________________
(b) Date Acquired _______________________
(c) Purchase Price $______________________
(d) Present FMV(Date of Valuation)$______________________
(e) First Mortgage Bal.$______________________
(f) Second Mortgage Balance or Home Improvement Loan $______________________
(g) Net Value$______________________
(h) Monthly Payment$______________________
(i) Income from Property$______________________
6. BUSINESS/FARM ASSETS (For Each Asset)
1. Description of Asset_______________________
(a) In Possession of_______________________
(b) Date Acquired/Age _______________________
(c) Purchase Price $______________________
(d) Present FMV (Dateof Valuation) $______________________
(e) Debt Balance$______________________
(f) Net Value$______________________
(g) Monthly Payment $______________________
(h) Income from Property$______________________
7. FINANCIAL ASSETS (For Each Asset)
1. Description of Asset_______________________
(a) In Possession of_______________________
(b) Date Acquired/Age _______________________
(c) Purchase Price $______________________
(d) Present FMV (Dateof Valuation) $______________________
(e) Debt Balance$______________________
(f) Net Value$______________________
8. LIFE INSURANCE (For Each Policy)
a) Name of Company _________________
b) Policy No. _________________
c) Type of Insurance _________________
d) Face Amount _________________
e) Cash Value _________________
f) Loans _________________
g) Insured _________________
h) Beneficiary _________________
i) Owner _________________
9. PENSION PLAN AND/OR PROFIT SHARING PLAN
| Husband | Wife | |
| (a) Through employment: Value | ____________ | ____________ |
| (b) Private Plans(IRA, Keogh, SEP) Value | ____________ | ____________ |
| (c) Deferred Compensation Value | ____________ | ____________ |
| (d) Military Pension or Disability | Yes_ No_ | Yes_ No_ |
10. PERSONAL PROPERTY: (For Each Asset)
A. Household Items in Husband's Possession Description of Item Value
1. _____________________________
B. Household Items in Wife's Possession Description of Item Value
1. _____________________________
C. Household Items in Joint Possession Description of Item Value
1. _____________________________
D. Motor Vehicles (For Each Asset)
1. Year, Make, Model________________
(a) In Possession of________________
(b) Market Value ________________
(c) Encumbrances ________________
(d) Net Value________________
(e) Monthly Payments________________
E. Boats, Campers, Snowmobiles, Trailers (For Each Asset)
1. Year, Make, Model_________________
(a) In Possession of_________________
(b) Market Value _________________
(c) Encumbrances _________________
(d) Net Value_________________
(e) Monthly Payments_________________
F. Other Personal Property (For Each Asset)
1. Description of Item_________________
(a) In Possession of_________________
(b) Market Value _________________
(c) Encumbrances _________________
(d) Net Value_________________
(e) Monthly Payments_________________
11. DEBTS (Not listed previously)
A) 1. Secured debts:
(a) Creditor_________
(b) Total Amount Owing $________ (As of What Date)_________
(c) Monthly Payments$________
(d) When Incurred_________
(e) Party Obliged_________
(f) Collateral_________
(g) Date of final payment_________
TOTALS: Husband ________ Wife ____________ Joint ____________
B) 1. Unsecured debts: (Include Attorney's Fees and Costs)
(a) Creditor____________
(b) Total Amount Owing$________ (As of What Date)____________
(c) Monthly Payment$________
(d) When Incurred_________
(e) Party Obliged_________
(f) Consideration____________
(g) Date of final payment____________
TOTALS:Husband ____________ Wife ____________ Joint ____________
I hereby represent that the above is a complete disclosure of all property interests and liabilities, and that the values set forth are the best estimates of the property's market value.
______________________________________
[Plaintiff] [Defendant]
______________________________________
Attorney for [Plaintiff] [Defendant]
______________________________________
Attorney Identification Number
______________________________________
Address
N.D. R. Ct. XI app D
EXPLANATORY NOTE
Effective 3/1/2000