In the District Court of County, Utah. Court Address
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- Joleen Roberts
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1 My Name This is a private record. Address City, State, Zip Phone I am the In the District Court of County, Utah Court Address Financial Declaration v. Case Number Judge Commissioner Instructions: Unless there is a hearing at which the judge or commissioner must decide a financial question related to spouse support, child support, equitable allocation of property and debts or responsibility for attorney fees and court costs, do not file this form with the court. File only a certificate of service stating that the Financial Declaration has been served on the other parties and the date of service. The judicial services representative cannot complete this form for you. Use the Checklist to help you understand and complete this form. You must update this information if it changes. Keep a copy of all documents for your records. Page 1 of 11
2 Attend all court hearings. Attach the following to the completed Financial Declaration. Check all boxes that apply:! Additional pages as needed to complete paragraphs that don t have enough space. Write the paragraph number on the additional page.! Any documents referred to in this document.! The following documents required by Utah Rule of Civil Procedure 26.1 to be attached to this Financial Declaration: (Note: File this form with the court only if there is a hearing at which the judge or commissioner must decide a financial question related to spouse support, child support, equitable allocation of property and debts or responsibility for attorney fees and court costs. When filing this form with the court, attach only evidence of all earned and un-earned income for the 12 months before the petition in this case was filed, such as your most recent pay stub showing year-to-date wages and your most recent federal tax form 1040, 1040A or 1040EZ. Do not file the other attachments described here, unless the court directs you to do so.)! For the two tax years before the petition in this case was filed, complete federal and state income tax returns, including Form W-2, Form 1099, and Form K-1, and supporting tax schedules and attachments filed by you and by any entity in which you have a majority or controlling interest.! Pay stubs and other evidence of all earned and un-earned income for the 12 months before the petition in this case was filed.! All loan applications and financial statements prepared or used by the party completing the financial declaration within the 12 months before the petition in this case was filed.! Documents verifying the value of all real estate in which the party has an interest, including the most recent appraisal, tax valuation and refinance documents.! All statements for the 3 months before the petition in this case was filed for all financial accounts, including checking, savings, money market funds, certificates of deposit, brokerage, investment, and retirement.! If any of the documents required to be attached to this Financial Declaration are not reasonably available or are in the possession of the other party, then estimate the amounts entered on this Financial Declaration, and complete Paragraph (13) explaining the basis for the estimation and why the documents are not available. (1) Social Security Number. My Social Security Number is: (2) Employment Status. (A) (B) My occupation is:. I am unemployed. I am employed by: Page 2 of 11
3 Name of Employer Doing Business As (DBA) Address & Telephone Number (3) Gross Monthly Income. (Print your pre-tax income in the appropriate boxes below. Attach evidence of items listed, such as most recent pay stubs, federal and state tax returns for past 2 years, W- 2 forms, or a work history report from the Department of Workforce Services. For income that changes from month to month, calculate the annual total and divide by 12 months to list a monthly average.) My Gross Monthly Income $ $ Rental Income $ Business Income $ Interest Income $ Dividends Source of Income Work (Including self employment, wages, salaries, commissions, bonuses, tips and overtime) $ Retirement Income (Including pensions, 401(k), IRA, etc.) $ Worker s Compensation $ Social Security Disability (SSDI and SSI) $ Private Disability Insurance $ Social Security (Do not include SSDI or SSI) $ Unemployment Benefits $ Education Benefits $ Veteran s Benefits $ Alimony (from a prior marriage) $ Child Support (from a prior order) $ Payments from Civil Litigation $ Victim Restitution $ Public Assistance (Including FEP, welfare, etc.) Page 3 of 11
4 My Gross Monthly Income Source of Income $ Support from household members $ Support from non-household members $ (Describe) $ (Describe) $ Total Gross Monthly Income I have no income because: (4) Monthly Tax Deductions. (These are deductions required by law and which you do not make voluntarily. There may be other funds withheld from your paycheck that you will report in Paragraph (11), Monthly Expenses. Attach evidence of claims, such as most recent pay stubs, federal and state tax returns for past 2 years, W-2 forms, or a work history report from the Department of Workforce Services.) My Monthly Tax Deductions $ Federal Income Tax $ State Income Tax $ Municipal Income Tax $ FICA $ Medicare $ Total Monthly Tax Deductions (5) Net Monthly Income. Type of Tax Deduction $ Gross Monthly Income from (3) $ Monthly Tax Deductions from (4) $ = Net Income Page 4 of 11
5 (6) Real Property. (Attach evidence of items listed, such as mortgage statements, loan documents, most recent appraisal, basis of valuation, etc.) (A) Home Address Date Acquired In Whose Name? Original Cost Current Value First Mortgage or Lien Holder (Name & Address) Amount Owed Monthly Payments Second Mortgage or Lien Holder (Name & Address) Amount Owed Monthly Payments (B) Real Property Address Date Acquired In Whose Name? Original Cost Current Value First Mortgage or Lien Holder (Name & Address) Amount Owed Monthly Payments Second Mortgage or Lien Holder (Name & Address) Amount Owed Monthly Payments (7) Personal Property. (Attach evidence of items listed, such as receipts, loan documents, basis of current value, etc.) Property (Such as vehicles, boats, trailers, major equipment, etc.) Vehicle (Year, Make, Model) Lien Holder (Name & Address) In Whose Name? Current Value Amount Owed Monthly Payments Vehicle (Year, Make, Model) $ $ Page 5 of 11
6 Property (Such as vehicles, boats, trailers, major equipment, etc.) (Describe) Lien Holder (Name & Address) In Whose Name? Current Value Amount Owed Monthly Payments (Describe) $ (Describe) $ $ (8) Business interests. (Attach evidence of items listed.) Business Name Address & Phone Nature of Business Percent Owned By Current Value % % $ % % $ (9) Financial Assets. (Attach evidence of items listed, including last 3 months of bank statements, contracts, etc.) Asset Bank or Credit Union Account Name of Institution (Name & Address) Names on Account Current Balance Page 6 of 11
7 Asset Bank or Credit Union Account Name of Institution (Name & Address) Names on Account Current Balance Stocks, Bonds, Securities, Money Market Fund Stocks, Bonds, Securities, Money Market Fund Retirement Account (Pension, 401(k), IRA, etc.) Plan Name Plan Representative Retirement Account (Pension, 401(k), IRA, etc.) Plan Name Plan Representative Profit Sharing Plan $ $ Profit Sharing Plan Annuity Annuity Page 7 of 11
8 Asset Money Owed to Parties Cash Life Insurance Life Insurance (Describe) Name of Institution (Name & Address) Names on Account Current Balance Face Value $ Cash Value $ Face Value $ Cash Value $ (10) Debts. (Do not include amount owed on property reported in Paragraphs (7) and (8). (Attach evidence of items listed, such as credit card statements, loan documents, leases, bills, etc.) Debt Owed To (Name & Address of Creditor) Purpose of Debt (Such as credit card, cash loan, installment payment, etc.) In Whose Name? Amount Owed Monthly Payments Page 8 of 11
9 Debt Owed To (Name & Address of Creditor) Purpose of Debt (Such as credit card, cash loan, installment payment, etc.) In Whose Name? Amount Owed Monthly Payments (11) Monthly Expenses. (Include amounts other than taxes withheld from your paycheck. For expenses that change from month to month, calculate the annual total and divide by 12 months to list a monthly average. Include amounts you pay for yourself and any children or other dependents in your household.) My Monthly Expenses Type of Expense $ Rent or mortgage $ Real property taxes $ Real property insurance $ Real property maintenance $ Food and household supplies $ Clothing $ Laundry and dry cleaning $ Automobile loan $ Automobile insurance $ Automobile gasoline $ Automobile maintenance $ Public transportation $ Electricity $ Gas $ Water, sewer and garbage $ Telephone $ Paid television (Cable, Satellite, Etc.) $ Internet $ Garnishments $ Alimony (from prior marriage) $ Child support (from prior order) $ Child care $ Education (children) Page 9 of 11
10 My Monthly Expenses Type of Expense $ Education (self) $ Extra-curricular activities (children) $ Health care insurance premiums $ Health care expenses $ insurance (Describe) $ Credit cards $ Union or other dues $ 401K or other retirement or pension fund contribution $ Savings plan contribution $ Entertainment $ Donations $ Gifts $ (Describe) $ Total (12) Estimated Amounts. I have estimated all or some of the amounts entered in the Paragraphs above. Paragraph Item estimated Amount estimated Basis for estimation (13) Unavailable Documents. I have not attached all or some of the documents required by Utah Rule of Civil Procedure 26.1 to support this Financial Declaration. They are not available to me. The following documents are not available to me because Page 10 of 11
11 The following documents are not available to me because I declare under criminal penalty of Utah Code Section 78B that: the information in this Financial Declaration about myself is true and correct; any information about the other party is true and correct or is an estimate to the best of my information and belief; I have disclosed everything that is relevant to my financial status; and I understand that if I fail to fully disclose all assets and income in the Financial Declaration and attachments I may be subjected to sanctions under Utah Rule of Civil Procedure 37 including an award of non-disclosed assets to the other party, attorney s fees or other sanctions deemed appropriate by the court. Date Sign here Typed or Printed Name Page 11 of 11
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