Indiana > Local County > Hamilton > Circuit-Superior Court > General
Financial Declaration 402B - Indiana
| Financial Declaration Form. This is a Indiana form and can be used in General Circuit-Superior Court Hamilton Local County . |
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Sheet1 FINANCIAL DECLARATION LR 29-FL00-402.10 Form 402B State of Indiana County of Hamilton in re: the marriage of Petitioner and In the Hamilton Cause No. Court Respondent HUSBAND: Name Address Employer Attorney Address Telephone WIFE: Name Address Employer Attorney Address Telephone FINANCIAL DECLARATION OF: GROSS WEEKLY INCOME attach last 3 paystubs 1 Salaries and Wages 2 Pension/Retirement/Social Security/Disability/Unemployment/Worker's Comp. Child support received from prior marriage 3 4 Dividends and interest 5 Rents / royalties less necessary and ordinary expenses 6 Business / self-employment income not after expenses 7 Commission / bonus / tips All other sources 8 9 TOTAL GROSS WEEKLY INCOME (Lines 1-8) WEEKLY DEDUCTIONS 10 Weekly court ordered child support for prior child(ren) 11 Weekly legal duty child support for prior child(ren) 12 Weekly health insurance premium (for children of marriage only) 13 Weekly alimony/support/maintenance paid to prior spouse amount actually paid 14 Self-employed tax (½ of weekly self employment taxes) 15 Weekly available income 16 Work related child care costs of custodial parent 17 Extraordinary health care expenses uninsured only 18 Extraordinary educational expenses 19 TOTAL GROSS WEEKLY DEDUCTIONS FROM GROSS INCOME 20 TOTAL NET WEEKLY INCOME MONTHLY EXPENSES and DEDUCTIONS FROM INCOME 1 Federal income taxes Page 1 Amount $0.00 $0.00 $0.00 $0.00 Amount American LegalNet, Inc. www.FormsWorkFlow.com Sheet1 2 State income taxes 3 Local income taxes 4 Social Security Taxes 5 Retirement / pension fund (mandatory)(optional) 6 Rent / mortgage payment (primary residence) 7 Residence property taxes / insurance 8 Maintenance on residence (lawn care,maid/cleaning, pool, HOA dues, etc) 9 Food and supplies eat at home / out with friends and children 10 Electricity 11 Gas, oil and wood heating 12 Water, sewer, solid waste, trash collection 13 Telephone (monthly base) 14 Telephone (long distance charges only) 15 Personal clothing (shoes, shoe repair, alterations) 16 Personal expenses (hair, cosmetics, tobacco, film, cards, postage) 17 Special work expenses (uniform, safety shoes, dues, parking) Laundry and dry cleaning 18 19 Automobile loan payment Automobile gas, oil car wash 20 21 Automobile repairs Automobile license plates, excise, and auto club 22 Automobile insurance 23 24 Cable television Medical and dental expenses (prescription / uninsured expenses only) estimated 25 26 Life insurance Health insurance 27 Disability, accident and other insurance 28 29 Entertainment (hobbies, travel, clubs, recreation) Charitable/church contributions 30 31 Books, magazines, and newspapers Home tax preparation (non-reimbursable business expense) 32 Children clothing and shoes 33 34 Children allowance, membership in scouts, uniforms, fees Children school lunches 35 36 Children book rental and tuition Children lessons, extracurricular activities, and tutors 37 38 39 40 Installment Payments H W J Current Balance TOTAL monthly expenses and deductions from gross income Average weekly monthly expenses and deductions from gross income Household Furnishings/Furniture Electronic A. Equipment, Appliances Gross Value Debt 1 In Husband's Possession In Wife's Possession 2 Page 2 $0.00 $0.00 Net H W J American LegalNet, Inc. www.FormsWorkFlow.com Sheet1 B. Vehicles (boats, Rvs, (Make / Model / Year) 3 4 5 6 7 Cash/Accounts/CDs (Name of bank account, last four digits of account number/account type) 8 9 10 11 12 13 14 Securities / Stocks / Bonds 15 16 17 18 Real Estate (including mobile homes) Fair Market Val. Mortgage Net Value Marital Residence (address) 19 C. D. E. 20 First mortgagor: Second mortgagor: Other residence (address) F. G. First mortgagor: Second mortgagor: Deferred compensation profit sharing pension plans, Keoghs, IRSs, 401(k), SEP 21 22 23 24 25 26 27 28 Business Interest 29 30 % Vested Vested FMV H W J % Interest % FMV H W J H. I. Life Insurance (term and group) 31 32 33 Life Insurance (whole) 34 Face Amt. Policy No. Beneficiary H W J Cash Value Loan Amt. Page 3 % Interest H W J American LegalNet, Inc. www.FormsWorkFlow.com Sheet1 35 36 J Collections, jewelry, antiques, silver, china Value Debt Net Value H W J 37 38 39 40 41 42 43 List names, ages, and relationships of persons living in your household: Are other persons in your household working? If so, who? Occupation: Employer: I declare under the penalties of perjury that the foregoing, including any attachments(s), is true and correct to the best of my knowledge and belief. Signature: Printed Name: Dated: You are under a duty to supplement or amend this Financial Declaration prior to hearing if you learn the information provided is incorrect or the information provided is no longer true. Prepared by: Page 4 American LegalNet, Inc. www.FormsWorkFlow.com
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