Sworn Financial Statement {JDF 1111SC}

JDF 1111 SC R 1 /1 8 SWORN FINANCIAL STATEMENT FORM 35.2 Page 1 of 7 District Court Denver Juvenile Court County, Colorado Court Address: I n re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co - Petitioner/Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E - mail: FAX Number: Atty. Reg. #: 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 consist s 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 - P etitioner /Respondent $ 1. Monthly Income (Convert annual, bi - monthly, and weekly amounts to monthly amounts . ) Gross M onthly I ncome (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, self - employment, business income , other jobs, and monthly reimbursed expenses . $ Social Security Benefits (SSA) SSDI (Disability insurance entitlement program) SSI (supplemental income need based) $ U Pension & Retirement Benefits Interest & Dividends Public Assistance (TANF) Other - T otal Monthly Income $ Miscellaneous Income Royalties, Trusts , and Other Investments $ Contributions from Other s $ income. Source of Income: All other sources, i.e. personal injury settlement, non - reported income, etc. Rental Net Income Expense Accounts Child Support from O thers Other - Spousal /Partner Support from Others Other - Total Monthly Miscellaneous Income $ T otal Income $ American LegalNet, Inc. www.FormsWorkFlow.com JDF 1111 SC R 1 /1 8 SWORN FINANCIAL STATEMENT FORM 35.2 Page 2 of 7 2. Monthly Deductions (Mandatory and Voluntary) Mandatory Deductions Cost Per Month Cost Per Month Federal Income Tax $ State /Local Income Tax $ PERA/Civil Service Social Security Tax Medicare Tax Other - Total Mandatory Deductions $ Voluntary Deductions Cost Per Month Cost Per Month Life and Disability Insurance $ Stock s/Bonds $ Health, Dental, Vision Insurance Premium T otal number of people covered on Plan Retirement & Deferred Compensation Child Care (deducted from salary) Other - Flex Benefit Cafeteria Plan Other - Total Voluntary Deductions $ Total Monthly Deductions $ 3. M onthly 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 Cost Per Month 1 st Mortgage $ 2 nd Mortgage $ Insurance (Home/Rental) & Property Taxes (not included in mortgage payment) Fees Rent Other - Total Housing $ B. Utilities and Misc ellaneous Housing Services Cost Per Month Cost Per Month Gas & Electricity $ Water , Sewer , Trash Removal $ Telephone (local, long distance, cellular & pager) 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 Cost Per Month Groceries & Supplies $ Dining Out $ Total Food & Supplies $ D. Health Care Costs (Co - pays, Premiums, etc. ) Cost Per Month Cost Per Month Doctor & Vision Care $ Dentist and Orthodontist $ Medicine & RX Drugs Therapist Premiums (if not paid by employer) Other - Total Health Care $ American LegalNet, Inc. www.FormsWorkFlow.com JDF 1111 SC R 1 /1 8 SWORN FINANCIAL STATEMENT FORM 35.2 Page 3 of 7 E . T ransportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) Cost Per Month Cost Per Month Primary Vehicle Payment $ Other Vehicle Payments $ Fuel , Parking , and Maintenance Insurance & Registration /Tax Payments (yearly amount (s) 12) Bus & Commuter Fees Other - Total Transportation $ F . Cost Per Month Cost Per Month Clothing & Shoes $ Child Care $ Extraordinary Expenses i.e. Special Needs, etc. Misc. Expenses , i.e. T utor, Books, Activities, Fees , Lunch, etc. Tuition Other - $ G . Education for you - Please identify status: Full - time student Part - time student Cost Per Month Cost Per Month Tuition , Books, Supplies, Fees, etc. Other - Total Education $ H . Maintenance (Spousal/Partner Support) & C hild Support (that you pay) Cost Per Month Cost Per Month Maintenance Child Support This family $ This family $ O ther family O ther family Total Maintenance and Child Sup p ort $ I . Miscellaneous (Please list on - going expenses not covered in the sections above) Cost Per Month 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 - Total Miscellaneous $ Total Monthly Expenses (Totals from A I) $ American LegalNet, Inc. www.FormsWorkFlow.com JDF 1111 SC R 1 /1 8 SWORN FINANCIAL STATEMENT FORM 35.2 Page 4 of 7 4. Debts (unsecured) List unsecured d ebts 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, such as mortgages and car loans, because th at payment is already listed as an expense above, and the total of the debt is shown elsewhere as a deduction from value where that asset is listed, such as under Real Estate or Motor Vehicles. For name on account, "P" = Petitioner , "C = Co - Petitioner or Respondent , "J" = Joint. Name of Creditor Account Number (last 4 - digits only) P C/R J Date of Balance Balance Minimum Monthly Payment Required Reason for Which Debt was Incurred $ $ Unsecured Debt Balance $ $ Total Minimum Monthly Payment SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES) Total Income (from Page 1) $ A Total Monthly Deductions (from Page 2) $ B Total Monthly Net Income (A minus B ) $ Total Monthly Expenses (from Page 3 ) $ C Total M inimum M onthly P ayment Required - Debts Unsecured (from Page 4 ) $ D Total Monthly Expenses and Payments (C plus D) $ Net Excess o r Shortfall (Monthly Net Income less Monthly Expenses and Payments ) (+/ - ) $ American LegalNet, Inc. www.FormsWorkFlow.com JDF 1111 SC R 1 /1 8 SWORN FINANCIAL STATEMENT FORM 35.2 Page 5 of 7 5. Assets You MUST disclose all assets correctly. stating affirmatively that you or the other party , do not have assets in that category . Please attach additional cop i es of page s 5 & 6 to identify your assets, if necessary . If the parties are married or partners in a civil union , check under the heading J oint (J) all assets acquired during the marriage /civil union but not by gift or inheritance. Under the headings of P etitioner (P) or Co - Petitioner/Respondent (C/R) , check assets owned before this ma rriage /civil union and assets acquired by gift or inheritance . If the parties were NEVER married to each other or are using this form to modify child support , Petitioner (P) or Co - Petitioner/Respondent (C/R ) . - Petitioner or Respondent, "J" = Joint. A. Real Estate (Address or Property Description and Name of Creditor/ Lender) None P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed) $ $ $ Total $ $ $ B . Motor Vehicles & Recreation Boats, etc.) (Year, Make, Model) (Name of Creditor/Lender) None P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed) Total $ $ $ C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution) None P C/R J Type of Account Account # (last 4 - digits only) Balance as of Today $ Total $ D. Life Insurance (Name of Company/Benefi