Colorado > Statewide > Domestic Relations
Sworn Financial Statement - Form 35.2 JDF 1111 - Colorado
| Sworn Financial Statement - Form 35.2 Form. This is a Colorado form and can be used in Domestic Relations Statewide . |
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District Court Denver Juvenile Court ___________________ County, Colorado Court Address: In re: The Marriage of: Parental Responsibilities concerning: ______________________________________________________ Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Phone Number:__________ E-mail:___________________________ FAX Number:___________ Atty. Reg. #: __________________ COURT USE ONLY Case Number: Division ______ Courtroom _______ SWORN FINANCIAL STATEMENT I, ___________________________________________________ (full name) am am not currently employed. I am employed ____ hours per week. I am paid weekly bi-weekly twice a month monthly. My pay is based on a Monthly Salary Hourly rate of $__________ Other: _________________________ Date employment began _______________________________. My occupation is: ____________________________ Name of employer: _______________________________ Address of employer: _________________________________________________________________________ If unemployed, what date did you last work? _______________________ I am unemployed due to disability involuntary layoff at work other: ________________________________ This household consists of _____ adult(s), and ______ minor child(ren). I believe the monthly gross income of the other party is $___________. Annual gross income (last tax year 20__) for Petitioner $ _________, Co-Petitioner/Respondent $ __________ 1. Monthly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.) $ Social Security Benefits (SSA) Gross Monthly Income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, selfemployment, business income, other jobs, and monthly reimbursed expenses. Unemployment & Veterans' Benefits Pension & Retirement Benefits Public Assistance (TANF) SSDI (Disability insurance entitlement program) SSI (supplemental income need based) $ Disability, Workers' Compensation Interest & Dividends Other - ___________________ Total Monthly Income Miscellaneous Income Royalties, Trusts, and Other Investments Dependent Children's monthly gross income. Source of Income: __________ Rental Net Income Child Support from Others Spousal Support from Others $ Contributions from Others All other sources, i.e. personal injury settlement, non-reported income, etc. Expense Accounts Other - ___________________ Other - ___________________ $ $ Total Monthly Miscellaneous Income Total Income JDF 1111 R4/10 SWORN FINANCIAL STATEMENT FORM 35.2 Page 1 of 7 $ $ American LegalNet, Inc. www.FormsWorkFlow.com 2. Monthly Deductions (Mandatory and Voluntary) Mandatory Deductions Federal Income Tax PERA/Civil Service Medicare Tax Voluntary Deductions Life and Disability Insurance Health, Dental, Vision Insurance Premium Total number of people covered on Plan Î Cost Per Month $ State/Local Income Tax Social Security Tax Other - ___________________ $ Cost Per Month Total Mandatory Deductions Cost Per Month $ Stocks/Bonds Retirement & Deferred Compensation Other - ____________________ Other - ____________________ $ Cost Per Month $ Child Care (deducted from salary) Flex Benefit Cafeteria Plan Total Voluntary Deductions Total Monthly Deductions $ $ 3. Monthly Expenses Note: List regular monthly expenses below that you pay on an on-going basis and that are not identified in the deductions above. A. Housing Cost Per Month 1 Mortgage Insurance (Home/Rental) & Property Taxes (not included in mortgage payment) Rent st Cost Per Month 2 Mortgage Condo/Homeowner's/Maintenance Fees Other - ________________ nd $ $ Total Housing B. Utilities and Miscellaneous Housing Services Cost Per Month Gas & Electricity $ Telephone (local, long distance, cellular & pager) $ Cost Per Month Water, Sewer, Trash Removal Property Care (Lawn, snow removal, cleaning, security system, etc.) $ Internet Provider, Cable & Satellite TV Other - ____________________ $ Total Utilities and Miscellaneous Housing Services C. Food & Supplies Cost Per Month Groceries & Supplies $ Dining Out Cost Per Month Total Food & Supplies D. Health Care Costs (Co-pays, Premiums, etc.) Cost Per Month Doctor & Vision Care $ Medicine & RX Drugs Premiums (if not paid by employer) $ $ Cost Per Month Dentist and Orthodontist Therapist Other - ____________________ $ Total Health Care JDF 1111 R4/10 SWORN FINANCIAL STATEMENT FORM 35.2 Page 2 of 7 $ American LegalNet, Inc. www.FormsWorkFlow.com E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) Cost Per Cost Per Month Month Primary Vehicle Payment $ Other Vehicle Payments $ Fuel, Parking, and Maintenance Insurance & Registration/Tax Payments (yearly amount(s) y12) Bus & Commuter Fees Other - ________________ Total Transportation F. Children's Expenses and Activities Cost Per Month Clothing & Shoes Extraordinary Expenses i.e. Special Needs, etc. Tuition $ Child Care Misc. Expenses, i.e. Tutor, Books, Activities, Fees, Lunch, etc. Other - ________________ $ Cost Per Month $ Total Children's Expenses and Activities G. Education for you - Please identify status: Full-time student Part-time student Cost Per Month Tuition, Books, Supplies, Fees, etc. Other - ________________ $ Cost Per Month $ Total Education H. Maintenance & Child Support (that you pay) Cost Per Month Spousal Maintenance $ This family Cost Per Month Other family This family Other family Child Support $ $ Total Maintenance and Child Support I. Miscellaneous (Please list on-going expenses not covered in the sections above) Cost Per Month Recreation/Entertainment $ Personal Care (Hair, Nail, Clothing, etc.) Legal/Accounting Fees Subscriptions (Newspapers, Magazines, etc.) Charity/Worship Movie & Video Rentals Vacation/Travel/Hobbies Investments (Not part of payroll deductions) Membership/Clubs Home Furnishings Pets/Pet Care Sports Events/Participation Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Cost Per Month $ Total Miscellaneous $ Total Monthly Expenses (Totals from A I) $ JDF 1111 R4/10 SWORN FINANCIAL STATEMENT FORM 35.2 Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com 4. Debts (unsecured) List unsecured debts such as credit cards, store charge accounts, loans from family members, back taxes owed to the I.R.S., etc. Do not list debts that are liens against your property, su
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