Family Law Assignment

IN THE CIRCUIT COURT OF THE FIFTH JUDICIAL CIRCUIT,

IN AND FOR MARION COUNTY, FLORIDA

CASE NO.: 42-2016-DR-

IN RE: The Marriage of:

HS,

Husband,

and

WF,

Wife.

___________________________________________/

CERTIFICATE OF COMPLIANCE WITH MANDATORY DISCLOSURE

Husband/Wife, HS/WF, has complied with the mandatory disclosure required by Florida Family Law Rule 12.285, as follows:

1. FOR TEMPORARY FINANCIAL RELIEF, ONLY:

The date the following documents were served:__________________________.

[Check all that apply]

______ a. Financial Affidavit (Filing of a Financial Affidavit cannot be waived.)

( ) Florida Family Law Rules of Procedure Form 12.902 (b) (short form)

( ) Florida Family Law Rules of Procedure Form 12.902 (c) (long form)

______ b. ( ) All personal (1040) federal tax, gift tax, and intangible personal property tax returns for the preceding year; or

( ) Transcript of tax return as provided by IRS form 4506; or

( ) IRS forms W-2, 1099, and K-1 for the past year because the income tax return for the past year has not been prepared.

______ c. Pay stubs or other evidence of earned income for the 3 months before the service of the Financial Affidavit.

2. FOR INITIAL, SUPPLEMENTAL, AND PERMANENT FINANCIAL RELIEF:

The date the following documents were served:____________________________________.

[Check all that apply]

______ a. Financial Affidavit (Filing of a Financial Affidavit cannot be waived.)

Produced:

( ) Florida Family Law Rules of Procedure Form 12.902 (b) (short form)

( ) Florida Family Law Rules of Procedure Form 12.902 (c) (long form)

______ b. All personal (1040) federal and state income returns, gift tax returns, and intangible personal property tax returns for the preceding 3 years;

( ) IRS forms W-2, 1099, and K-1 for the past year because the income tax return for the past year has not been prepared.

Produced:

______ c. Pay stubs or other evidence of earned income for the 3 months before the service of the Financial Affidavit.

Produced:

______ d. A statement identifying the source and amount of all income for the 3 months before the service of the Financial Affidavit, if not reflected on the pay stubs produced.

Produced:

______ e. All loan applications and financial statements prepared for any purpose or used for any purpose within the 12 months preceding the service of the Financial Affidavit.

Produced:

______ f. All deeds to real estate in which I presently own or owned an interest within the past 3 years. All promissory notes in which I presently own or owned an interest within the last 12 months. All present leases in which I own an interest.

Produced:

______ g. All periodic statements for the last 3 months for all checking accounts and for the last 12 months for all savings accounts, money market funds, certificates of deposit, etc.

Produced:

______ h. All brokerage account statements for the last 12 months.

Produced:

______ i. Most recent statement for any pension, profit sharing, deferred compensation, or retirement plan (for example, IRA, 401(k), 403(b), SEP, KEOGH, etc.) and summary plan description for any such plan in which I am a participant or alternate payee.

Produced:

______ j. The declarations page, the last periodic statement, and the certificate for any group insurance for all life insurance policies insuring my life or the life my spouse.

Produced:

______ k. Corporate, partnership, and trust tax returns for the last 3 years, in which I have an ownership or interest greater than or equal to 30%.

Produced:

______ l. All premarital and marital agreements between the parties to this case.

Produced:

______ m. If a modification proceeding, all written agreements entered into between the parties at any time since the order to be modified was entered.

Produced:

______ n. All documents and tangible evidence supporting claims for unequal distribution of marital property, enhancement or appreciation in nonmarital property, or nonmarital status of an asset or debt.

Produced:

______ o. Any court order directing that I pay or receive spousal support (alimony) or child support.

Produced:

I understand that I am swearing or affirming under oath to the accuracy of my compliance with the mandatory disclosure requirements of Fla. Fam. L. R. P. 12.285 and that, unless otherwise indicated with specificity, this disclosure is complete. I further understand that the punishment for knowingly making a false statement or incomplete disclosure includes fines and/or imprisonment.

_________________________________

Husband/Wife

STATE OF FLORIDA

COUNTY OF MARION

SWORN TO or affirmed and signed before me, the undersigned authority, on this ___ day of ____________, 2016, by Husband/Wife, who is personally known to me or produced __________________ as identification.

________________________________________

Notary Public, State of Florida

My commission expires:

I HEREBY CERTIFY that a copy of the foregoing has been furnished by mail to ______________________, Jane K. Smith Esquire, Attorney for Husband/Wife, PO Box 771138, Ocala, Florida 34477, this _______ day of _______________________, 2016.

By_____________________________________

Attorney for Husband/Wife