Petitioner/Joint Petitioner A:

Respondent/Joint Petitioner B:

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 STATE OF WISCONSIN, CIRCUIT COURT,
case is filed. COUNTY
Enter the name of the
Petitioner/Joint Petitioner/Joint Petitioner A
Petitioner A.
On the far right, check Name (First, Middle and Last)
Petitioner/Joint Petitioner
A or Respondent/Joint and Financial Disclosure
Petitioner B.
Enter the name of the
Statement of
Respondent/Joint Petitioner B
Respondent/Joint Petitioner/Joint Petitioner A
Petitioner B.
Name (First, Middle and Last) Respondent/Joint Petitioner B
Enter the case number.
Case No.

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.

1. PROOF OF INCOME
 Attach a statement reflecting income earned to date for the current year.
 Attach most recent W-2 Statement.

2. 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

3. 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.
This person helps pay expenses
Name Relationship
Yes No
1.
2.
3.

FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.
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Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

4.
5.
6.
7.
8.

4. 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)

5. 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)

FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.
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Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

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)

6. 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 Ownership or Title Current Estimated
Amount
B = Joint Petitioner B T = Together Held by Possession Value
Owed
Today
Household Items A B T A B T
Household furniture & accessories

Household appliances

Kitchen equipment

China, silver, crystal

FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.
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Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

Jewelry

Clothing

Antiques

Art

Electronic equipment

Sports equipment

Recreational vehicles, boats

Tools

Other:

Other:

Automobiles: Estimated
Amount
Year, Make, Model A B T A B T Value
Owed
Today

Life Insurance Cash

Face
Name of Company & Policy # A B T Beneficiary Value
Amount
Today

Business Interests Type of % of Value MINUS

A B T
Name of Business & Address Business Ownership Indebtedness

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
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

Ownership or Title held by

Securities: Stocks, Bonds, Mutual Funds, A = Joint Petitioner A
Value
Commodity Accounts B = Joint Petitioner B
Today
Name of Company & # of shares T = Together
A B T

Pension, Retirement Accounts,

Deferred Compensation, 401K Plans, IRAs, % Vested Date of Value
Profit Sharing, etc. if known Valuation Today
Name of Company & Type of Plan A B T

Cash and Deposit Accounts

Type of Account # Balance
(Savings and Checking)
Account Last 4 digits Today
Name of Bank or Financial Institution A B T

Other Personal Property Type of

Value
Description of Asset A B T Property

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
Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

Ownership Acquired by
A = Joint Petitioner A G - Gift Date Value
Assets Acquired B = Joint Petitioner B I - Inherited Acquired Today
Description of Asset T = Together 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.
Who Currently Monthly Current
Creditor’s Name & Address Type of Obligation Pays Payment Balance
A B T

FA-4139V, 12/22 Financial Disclosure Statement §767.127, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.
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Petitioner/Joint Petitioner A:
Respondent/Joint Petitioner B:

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:
Fair Market Value on
Property / Asset Date of Disposal
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 Signature
name.
Print or Type Name
Enter the date on
which you signed
Address
your name.

Note: This signature Email Address Telephone Number

does not need to be
notarized.
Date State Bar No. (if any)

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