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Financial Declaration DRPSCU 01.1550 - Washington
| Financial Declaration Form. This is a Washington form and can be used in General Domestic Relations Statewide . |
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SUPERIOR COURT OF WASHINGTON COUNTY OF In re: NO. Petitioner, FINANCIAL DECLARATION and [ ] PETITIONER [ ] RESPONDENT (FNDCLR) Respondent. Name: Date of Birth: I. SUMMARY OF BASIC INFORMATION Declarants Total Monthly Net Incom(from 3.3 below)e $ Declarants Total Monthly Household Expenses (from 5.9 below) $ Declarants Total Monthly Debt Expenses (from 5.11 below) $ Declarants Total Monthly Expenses (from 5.12 below) $ Estimate of the other partys gross monthly incom(from 3.1f below)e [ ] $ [ ] unknown II. PERSONAL INFORMATION 2.1 Occupation: 2.2 The highest year of education completed: 2.3 Are you presently employed? [ ] Yes [ ] No a. If yes: (1) Where do you work. Employers name and address must be listed on the Confidential Information Form. FINANCIAL DECLARATION (FNDCLR) - Page 1 of 6 WPF DRPSCU 01.1550 (6/2004) - RCW 26.18.220 (1) <<<<<<<<<********>>>>>>>>>>>>> 2 (2) When did you start work there (month/year)? _______________________ b. If no: (1) When did you last work (month/year)? _______________________ (2) What were your gross monthly earnings? $ (3) 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 partys 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, muly ltipyour 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. Name Name a. Wages and Salaries $ $ b. Interest and Dividend Income $ $ c. Business Income $ $ d. Spousal Maintenance Received From ____________________________ $ $ e. Other Income $ $ f. Total Gross Monthly Incom(ea dd lines 3.1a through 3.1e)$ $ g. Actual Gross Income(Year-to -date) $ $ 3.2 MONTHLY DEDUCTIONS FROM GROSS INCOME. a. Income Taxes $ $ b. FICA/Self-employment Taxes $ $ c. State Industrial Insurance Deductions $ $ d. MANDATORY Union/Professional Dues $ $ e. Pension Plan Payments $ $ f. Spousal Maintenance Paid $ $ g. Normal Business Expenses $ $ h. Total Deductions from Gross Income $ $ (add lines 3.2a through 3.2g) 3.3 MONTHLY NET INCOME. (Line 3.1f minus line 3.2h or $ $ line 3 from the Child Support Worksheet(s).) FINANCIAL DECLARATION (FNDCLR) - Page 2 of 6 WPF DRPSCU 01.1550 (6/2004) - RCW 26.18.220 (1) <<<<<<<<<********>>>>>>>>>>>>> 3 3.4 MISCELLANEOUS INCOME. a. Child support received from other relationships $ $ b. Other miscellaneous incom(list soure ce and amounts) __________________________________________ $ $ __________________________________________ $ $ __________________________________________ $ $ __________________________________________ $ $ c. Total Miscellaneous Incom(ea dd lines 3.4a through 3.4b) $ $ 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) $ Electricity $ FINANCIAL DECLARATION (FNDCLR) - Page 3 of 6 WPF DRPSCU 01.1550 (6/2004) - RCW 26.18.220 (1) <<<<<<<<<********>>>>>>>>>>>>> 4 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 $ Total Health Care $ 5.7 PERSONAL EXPENSES (Not including children) Clothing $ Hair care/personal care expenses $ FINANCIAL DECLARATION (FNDCLR) - Page 4 of 6 WPF DRPSCU 01.1550 (6/2004) - RCW 26.18.220 (1) <<<<<<<<<********>>>>>>>>>>>>> 5 Clubs and recreation $ Education $ Books, newspapers, magazines, photos $ G ifts $ Other $ Total Personal Expenses $ 5.7 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) $ 5.10 INSTALLMENT DEBTS INCLUDED IN PARAGRAPHS 5.1 THROUGH 5.8. Description Month of Creditor of Debt Balance Last Payment 5.11 OTHER DEBTS AND MONTHLY EXPENSES NOT INCLUDED IN PARAGRAPHS 5.1 THROUGH 5.8. Description Month of Amount of Creditor of Debt Balance Last Payment Monthly Paymen t $ $ $ $ $ $ $ Total Monthly Payments for Other Debts and Monthly Expenses $ 5.12 TOTAL EXPENSES (Add Paragraphs 5.9 and 5.11) $ FINANCIAL DECLARATION (FNDCLR) - Page 5 of 6 WPF DRPSCU 01.1550 (6/2004) - RCW 26.18.220 (1) <<<<<<<<<********>>>>>>>>>>>>> 6 VI. ATTORNEY FEES 6.1 Amount paid for attorney fees and costs to date: $ 6.2 The source of this money was: 6.3 Fees and costs incurred to date: $ 6.4 Arrangements for attorney fees and costs are: 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 ________________________, [City] _________ [State] on ____________________ [Date]. Signature of Declarant Print or Type Name The following financial records are being provided to the other party and filed separately with the court. Financial records pertaining to myself: [ ] Individual [ ] Partnership or Corporate Income Tax returns for the years _____________ ______________________________________________including
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