A financial statement shall contain the following information about the defendant:

1. (a) His or her:

   1. (1) Name;
   2. (2) Address;
   3. (3) Telephone number;
   4. (4) Date of birth; and
   5. (5) Age;

2. (b) His or her marital status, whether:

   1. (1) Single;
   2. (2) Married;
   3. (3) Divorced;
   4. (4) Separated; or
   5. (5) Widowed;

3. (c) With respect to dependents personally supported by the defendant:

   1. (1) Their names;
   2. (2) Their addresses if different from that of the defendant;
   3. (3) Their relationship to the defendant; and
   4. (4) Their ages;

4. (d) For both the defendant and a spouse of the defendant, the amounts of the following kinds of funds available to each of them, individually:

   1. (1) Cash on hand;
   2. (2) Money in checking accounts;
   3. (3) Money in savings accounts;
   4. (4) Funds in stocks, bonds, trusts, certificates of deposit and similar investments; and
   5. (5) The total sum of the amounts provided for (1) through (4), above;

5. (e) For both the defendant and a spouse of the defendant, the amounts of the following received by each of them, individually, weekly, and monthly:

   1. (1) Take home pay in the form of wages or salary;
   2. (2) Alimony or maintenance received;
   3. (3) Child support received; and
   4. (4) The total sum of the amounts provided for (1) through (3), above;

6. (f) For the defendant and a spouse of the defendant, the following employment information:

   1. (1) Name of employer;
   2. (2) Address of employer; and
   3. (3) Whether employment is full time, part time or seasonal;

7. (g) The defendant's monthly housing costs in the form of:

   1. (1) Monthly rent or mortgage;
   2. (2) Utilities; and
   3. (3) The total sum of the costs provided for (1) and (2), above;

8. (h) The defendant's monthly loan payments, including the following information about such payments:

   1. (1) The payee(s);
   2. (2) The purpose(s) of the loan(s) being repaid;
   3. (3) The balance(s) due on the loan(s);
   4. (4) The amount(s) of the monthly payment(s); and
   5. (5) The total of all monthly loan payments;

9. (i) Additional monthly payments, such as alimony, child care and child support, including:

   1. (1) The payee(s);
   2. (2) The purpose(s) of the payment(s);
   3. (3) The sum(s) still owed;
   4. (4) The amount(s) of the monthly payment(s); and
   5. (5) The total of all such monthly payments; and

10. (j) With respect to the defendant's ownership of real estate and personal property:

    1. (1) Whether the defendant owns a house or other real estate, and if so:

       1. a. Identification of the real estate;
       2. b. The market value of such real estate;
       3. c. The identity of the mortgage holder on such real estate, if applicable; and
       4. d. The amount of the mortgage on such real estate, if applicable; and

    2. (2) Whether the defendant has, within the last 6 months, sold or transferred real estate or personal property worth $200.00 or more, and if so:

       1. a. Identification of such real estate or property;
       2. b. The identity of the transferee of such real estate or property;
       3. c. The value of such real estate or property; and
       4. d. The amount received for such real estate or property.

Source. (See Revision Note at chapter heading for Adm 1000) #8697, eff 8-3-06; ss by #9149, eff 5-1-08; ss by #10728, eff 11-25-14; ss by #13050, eff 7-1-20