Name
Address
City State Zip Code
Phone Number
Email Address
RESPONDENT PRO SE
MISSOULA COUNTY
In re the Marriage of:
________________________,
Petitioner,
and
________________________,
Respondent.
Cause No.: _____
Department No.: __
RESPONDENT’S PRELIMINARY
DECLARATION OF DISCLOSURE
OF ASSETS, DEBTS, INCOME,
AND EXPENSES
**WARNING: Montana law requires the full disclosure of all assets, debts, income and
expenses. Failure of either party to file a complete financial disclosure statement shall authorize
the Court to accept the statement of the other party as accurate. Any deliberately false statement
made hereon or on any schedules or attachments may subject you to the penalty of perjury or
other appropriate relief and may be considered a fraud upon the Court.
If you need additional space on which to list your assets, debts, income or expenses, please
attach additional sheets of paper as necessary. Do not write in the margins or on the reverse
sides of the pages of this document.
DO NOT FILE THIS DOCUMENT WITH THE CLERK OF COURT.
FILE A “NOTICE OF SERVICE OF PRELIMINARY DECLARATION OF
DISCLOSURE.”
FORM #56a
MONTANA FIRST JUDICIAL DISTRICT COURT
LEWIS AND CLARK
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 2 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
DISCLOSURE OF ASSETS
REAL ESTATE Estimated Value Name(s) on Title
Address:_____________________
Legal Desc:___________________
Secured Debt: Yes / No Amount:_
Lender:______________________
Address:_____________________
Legal Desc:___________________
Secured Debt: Yes / No Amount:_
Lender:______________________
VEHICLES / RECREATIONAL VEHICLES Estimated Value Name(s) on Title
Year/Make/Model:_____________
VIN#:_______________________
Loan on Vehicle: Yes / No Amount:
Lender:_______________________
Year/Make/Model:_____________
VIN#:_______________________
Loan on Vehicle: Yes / No Amount:
Lender:_______________________
Year/Make/Model:_____________
VIN#:_______________________
Loan on Vehicle: Yes / No Amount:
Lender:_______________________
Year/Make/Model:_____________
VIN#:_______________________
Loan on Vehicle: Yes / No Amount:
Lender:_______________________
Year/Make/Model:_____________
VIN#:_______________________
Loan on Vehicle: Yes / No Amount:
Lender:_______________________
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 3 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
BANK ACCOUNTS / CASH Balance as of
/ /
Name(s) on Account
Name of Bank:________________
Account # (Sealed – Sensitive Data Form)
Savings ____Checking _____Cert of Dep. Name of Bank:______________________
Account # (Sealed – Sensitive Data Form)
Savings ____Checking _____Cert of Dep. Name of Bank:______________________
Account # (Sealed – Sensitive Data Form)
Savings ____Checking _____Cert of Dep. Name of Bank:______________________
Account # (Sealed – Sensitive Data Form)
_____Savings _____Checking _____Cert of Dep.
PENSIONS, RETIREMENT, LIFE
INSURANCE, STOCKS, BONDS, SECURED
NOTES, MUTUAL FUNDS
Balance as of
/ /
Name(s) on Account
Description:
Description:
Description:
PERSONAL PROPERTY (including appliances, furniture, jewelry, art,
guns, etc.)
Estimated
Value
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 4 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
BUSINESS INTERESTS (including equipment, tools, livestock, etc.) Est.Value
OTHER ASSETS Est.Value
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 5 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
DISCLOSURE OF DEBTS
Any mortgages or secured debts should be listed with the real estate above.
Any vehicle loans should be listed with the vehicles above.
(List amounts owing for credit cards, utility bills, medical expenses, etc.)
Creditor Description Amount Name on Debt
DISCLOSURE OF INCOME
[ ] WIFE [ ] HUSBAND
Source of Income Amt/Month Source of Income Amt/Month
Wages, Salary, Commissions Food Stamps
Rents, Interests, Dividends Pension, Retirement
Self Employment Earnings Child Support
Unemployment / Wk. Comp. Dependent’s Benefits
Soc. Sec. Benefits / SSI Other:
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 6 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
Public Assistance
DISCLOSURE OF EXPENSES
[ ] WIFE [ ] HUSBAND
Description of Expense Amt/Month Description of Expense Amt/Month
Taxes, etc. withheld from
income
Property Insurance
Retirement Transportation
Health Insurance Car Insurance
Medical Expenses Student Loans
Housing (rent or mortgage) Utilities
Property Taxes Telephone
Clothing Food/Household Supplies
Child Care Child Support Payments
Other:
DATED this _ day of ______________________, 20____.
Signature of Respondent Pro se
FORM #56a- RESPONDENT’S PRELIMINARY DECLARATION OF DISCLOSURE Page 7 of 7
4th Judicial District Forms – Pro se Response to Petition for Dissolution (Revision Date: 04/13)
STATE OF MONTANA )
:ss.
COUNTY OF____________)
SUBSCRIBED AND SWORN TO before me this _ day of _________,
20____.
Name (printed)
(Seal) Notary Public for the State of Montana
Residing at:
My Commission Expires:
CERTIFICATE OF SERVICE
I, the undersigned, certify that I served the Preliminary Declaration of Disclosure on the
following person this _ day of ____________, 20____, by:
[ ] depositing the same in the U.S. Mail with postage pre-paid;
or
[ ] personally delivering this document to the following person.
(Insert Name
and Address
of Petitioner)
Signature of Respondent Pro se
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