Washington > Local County > Chelan > Superior Court > General
Financial Declaration - Washington
| Financial Declaration Form. This is a Washington form and can be used in General Superior Court Chelan Local County . |
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EXHIBIT A TO LR 94.04 SUPERIOR COURT OF WASHINGTON COUNTY OF CHELAN In re: NO. Petitioner, and FINANCIAL DECLARATION [ ] PETITIONER [ ] RESPONDENT (FNDCLR) Respondent. Name: Social Security Number: Date of Birth: I. SUMMARY OF BASIC INFORMATION Declarant's Total Monthly Net Income (from § 3.3 below) $ Declarant's Total Monthly Household Expenses (from § 5.9 below) $ Declarant's Total Monthly Debt Expenses (from § 5.11 below) $ Declarant's Total Monthly Expenses (from § 5.12 below) $ Estimate of the other party's gross monthly income (from § 3.1f below) $ unknown [] [] II. PERSONAL INFORMATION 2.1 2.2 2.3 Occupation: The highest year of education completed: Are you presently employed? [ ] Yes [ ] No a. If yes: (1) Where do you work (name and address)? American LegalNet, Inc. www.FormsWorkflow.com (2) When ______________________ b. If no: (1) When _______________________ (2) $ (3) did did you start work there (month/year)? you last work (month/year)? What were your gross monthly earnings? Why are you presently unemployed? III. INCOME INFORMATION If child support is at issue, complete the Washington State Child Support Worksheet(s), skip Paragraphs 3.1 and 3.2. If maintenance, fees, costs or debts are at issue and child support is NOT an issue this entire section should be completed. (Estimate of other party's income information is optional.) 3.1 GROSS MONTHLY INCOME. If you are paid on a weekly basis, multiply your weekly gross pay by 4.3 to determine your monthly wages and salaries. If you are paid every two weeks, multiply your gross pay by 2.15. If you are paid twice monthly, multiply your gross pay by 2. If you are paid once a month, list that amount below. Petitioner Respondent a. $ b. $ c. $ d. $ e. $ f. $ Total Gross Monthly Income (add lines 3.1a through 3.1e) $ Other Income $ Spousal Maintenance From Other Relationships $ Business Income $ Interest and Dividend Income $ Wages and Salaries $ American LegalNet, Inc. www.FormsWorkflow.com g. $ 3.2 Actual Gross Income (Year to date) $ MONTHLY DEDUCTIONS FROM GROSS INCOME. a. $ b. $ c. $ d. $ e. $ f. $ g. $ h. $ Total Deductions from Gross Income (add lines 3.2a through 3.2g) $ Normal Business Expenses $ Spousal Maintenance Paid $ Pension Plan Payments $ MANDATORY Union/Professional Dues $ State Industrial Insurance Deductions $ FICA/Self-employment Taxes $ Income Taxes $ 3.3 MONTHLY NET INCOME. (Line 3.1f minus line 3.2h or $ line 3 from the Child Support Worksheet(s).) $ 3.4 MISCELLANEOUS INCOME. a. $ b. Other miscellaneous income (list source and amounts): $ _____________________________________________________ $ $ _____________________________________________________ $ $ $ Child support received from other relationships $ American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________ $ $ _____________________________________________________ $ $ c. Total Miscellaneous Income (add lines 3.4a through 3.4c) $ $ 3.5 Income of Other Adults in Household $ $ 3.6 If the income of either party is disputed, state monthly income you believe is correct and explain below: IV. AVAILABLE ASSETS 4.1 Cash on hand $ 4.2 On deposit in banks $ 4.3 Stocks and Bonds, cash value of life insurance $ 4.4 Other liquid assets: $ V. MONTHLY EXPENSE INFORMATION Monthly expenses for myself and ____________ dependents are: (Expenses should be calculated for the future, after separation, based on the anticipated residential schedule for the children.) 5.1 HOUSING. Rent, 1st mortgage or contract payments Installment payments for other mortgages or encumbrances Taxes & insurance (if not in monthly payment) Total Housing $ 5.2 UTILITIES. Heat (gas & oil) $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com Electricity Water, sewer, garbage Telephone Cable Other Total Utilities $ 5.3 FOOD AND SUPPLIES. Food for ___________ persons Supplies (paper, tobacco, pets) Meals eaten out Other Total Food Supplies $ 5.4 CHILDREN. Day Care/Babysitting Clothing Tuition (if any) Other child related expenses Total Expenses Children $ 5.5 TRANSPORTATION. Vehicle payments or leases Vehicle insurance & license Vehicle gas, oil, ordinary maintenance Parking Other transportation expenses Total Transportation $ 5.6 HEALTH CARE. (Omit if fully covered) Insurance Uninsured dental, orthodontic, medical, eye care expenses Other uninsured health expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ American LegalNet, Inc. www.FormsWorkflow.com Total Health Care $ 5.7 PERSONAL EXPENSES (Not including children). Clothing Hair care/personal care expenses Clubs and recreation Education Books, newspapers, magazines, photos Gifts Other Total Personal Expenses $ $ $ $ $ $ $ $ 5.8 MISCELLANEOUS EXPENSES. Life insurance (if not deducted from income) Other _____________________________________________ Other _____________________________________________ Total Miscellaneous Expenses $ $ $ $ 5.9 TOTAL HOUSEHOLD EXPENSES (The total of Paragraphs 5.1 through 5.8) $ INSTALLMENT DEBTS INCLUDED IN PARAGRAPHS 5.1 THROUGH 5.8. Description of Debt Month of Last Payment 5.10 Creditor Balance 5.11 OTHER DEBTS AND MONTHLY EXPENSES NOT INCLUDED IN PARAGRAPHS 5.1 THROUGH 5.8. Description Monthly Creditor Payment of Debt Balance Month of Last Payment $ American LegalNet, Inc. www.FormsWorkflow.com $ $ $ $ $ $ Total Monthly Payments for Other Debts and Monthly Expenses $ 5.12 TOTAL EXPENSES (Add Paragraphs 5.9 and 5.11) $ VI. ATTORNEY FEES 6.1 Amount paid for attorney fees and costs to date: $ The source of this money was: Fees and costs incurred to date: $ Arrangements for attorney fees and costs are: 6.2 6.3 6.4 6.5 Other: I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signed at ______________________________________ on _________________________. [Place] [Date] American LegalNet, Inc. www.FormsWorkflow.com Signature Print or Type Name THE OTHER PARTY MUST BE SERVED COPIES OF YOUR TAX RETURNS FROM THE LAST TWO YEARS AND COPIES OF YOUR PAY STUBS FOR THE LAST SIX MONTHS TO VERIFY YOUR INCOME. YOU SHOULD ALSO BRING COPIES OF YOUR TAX RETURNS FROM THE LAST TWO YEARS AND COPIES OF YOUR PAY STUBS FOR THE LAST SIX MONTHS TO YOUR COURT HEARINGS. American LegalNet, Inc. www.FormsWorkflow.com
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