All sections must be completed. If an amount is unknown, write unknown, if the question is inapplicable, write n/a. If a question requires further documentation or an additional schedule, please attach.

I, __________, declare under oath that my personal information is:

Name: ____________________

Address: ____________________

____________________

____________________

Place of Birth: ____________________

Date/Place of Marriage: ____________________

Date of Separation: ____________________

Spouse's Name: ____________________

My occupation is: ____________________

I am currently employed at: ____________________

I earn ___ per ___ and work ___ hours

I am paid ___ (weekly, bi-weekly, monthly, etc ... )

My year to date earnings are __________ (attach pay stubs)

******** My monthly gross from my employment is __________.

I hereby acknowledge that the information contained in __________'s Mandatory Case Disclosure is a true and accurate reflection of the financial disputes in this matter and that there are no additional assets, debts or issue which require disclosure, to the best of my knowledge.

If maintenance is an issue or there are property distribution issues, please proceed to use the Ml Mandatory Disclosure Form.

LAY WITNESSES

Name the lay witnesses (non-experts) you expect to call at trial and the issues you expect them to testify about (i.e. friends, family members, etc ... ):

EXPERT WITNESS

Name the expert witnesses (doctors, accountants, etc ... ) you expect to testify for you at trial and the issue you expect them to address:

LENGTH OF TRIAL

How many days do you expect this case to take? ___ hours ___ days

OTHER LEGAL ACTIONS

Please give the style of the case, the case number, name of the Court or administrative agency for any case you are a party to or have been a party to within the last year, as well as a brief description of the nature of the case and the present status:

REQUIRED ATTACHMENTS

I have attached:

I hereby certify that the information I have provided in this document is true to the best of my knowledge, information and belief.

STATE OF KENTUCKY

COUNTY OF WARREN

Subscribed and sworn to before me by __________ on this the ___ day of __________, 20 ___.

IT IS HEREBY CERTIFIED that a copy of the foregoing Preliminary or Final Verified Disclosure Statement Acknowledgement (with attachments) was mailed on this the ___ day of __________, 20 ___.