STATE OF INDIANA: XXX COURT: XXX COUNTY VERIFIED FINANCIAL DECLARATION. Respondent
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1 STATE OF INDIANA: XXX COURT: XXX COUNTY VERIFIED FINANCIAL DECLARATION vs. Petitioner Respondent Cause No. Date: HUSBAND/FATHER NAME: ADDRESS: SSN: OCCUPATION: EMPLOYER: BIRTH DATE: WIFE/MOTHER NAME: ADDRESS: SSN: OCCUPATION: EMPLOYER: BIRTH DATE: SPACE BELOW FOR CLERK S USE ONLY. GROSS WEEKLY SALARY, WAGES, COMMISSIONS. GROSS WEEKLY Pension/Retirement/Social Security/Disability/Unemployment/Worker's Comp.. GROSS WEEKLY CHILD SUPPORT rec'd from any prior marriage. GROSS WEEKLY DIVIDENDS and Interest 5. GROSS WEEKLY RENTS/ROYALTIES less any ordinary and necessary expenses (attach calculations) 6. GROSS WEEKLY Business/Self-Employment Inc. less ordinary and necessary expenses (attach calculations) 7. ALL OTHER SOURCES (Specify) 8. TOTAL GROSS WEEKLY INCOME (Total of lines -7) 9. MINUS WEEKLY COURT ORDERED CHILD SUPPORT for prior children (Amounts actually paid) 0. MINUS WEEKLY LEGAL DUTY CHILD SUPPORT for prior children. MINUS WKLY HEALTH INS PREMIUMS (children of this marriage). MINUS WKLY ALIMONY/SUPPORT/MAINTENANCE paid to prior Spouses (amounts actually paid). WEEKLY AVAILABLE INCOME (Line 8 less Lines 9 through ). WEEKLY WORK RELATED CHILD CARE COSTS for Custodial Parent to Work for Children of this marriage only 5. WEEKLY EXTRAORDINARY HEALTHCARE EXP. (children of this marriage) 6. WEEKLY EXTRAORDINARY EDUCATION EXP. (children of this marriage) *Includes bonuses; alimony & maintenance rec'd from prior marriages; capital gains; trust income; gifts; prizes; n kind benefits from employment such as company car, free housing, reimbursed meals, DO NOT include ADC, SSI, General Assistance, Food Stamps
2 . FEDERAL INCOME TAXES (weekly deductions x.). STATE INCOME TAXES (weekly deductions x.). LOCAL INCOME TAXES (weekly deductions x.). SOCIAL SECURITY TAXES (weekly deductions x.) 5. RETIREMENT/PENSION FUND (Mandatory/Optional) Wkly Ded. x.) 7. Residence/Property Taxes/Insurance-if not included in mortgage payment (Total for year divided by ) 8. MAINTENANCE ON RESIDENCE 0. ELECTRICITY (Total for year divided by ). GAS (Total for year divided by or monthly budget amt). WATER/SEWER/SOLID WASTE/TRASH COLLECTION (total for year divided by ). TELEPHONE (including long distance charges) 5. MEDICAL/DENTAL EXPENSES (not reimbursed by insurance) 7. AUTOMOBILE (gas/oil) 9. AUTOMOBILE INSURANCE (total for year divided by ) 0. LIFE INSURANCE. HEALTH INSURANCE (exclude pymts for children shown on Pg., line )-ALL PAYMENT. DISABILITY/ACCIDENT/OTHER INSURANCE (please specify). ENTERTAINMENT (clubs, soc. oblig., travel, recreation, cable TV). CHARITABLE/CHURCH CONTRIBUTIONS 5. PERSONAL EXPENSES (Haircuts, cosmetics, tobacco, alcohol, etc.) 6. BOOKS/MAGAZINES/NEWSPAPERS 7. EDUCATION/SCHOOL EXP. (self & children you have custody of) 8. DAYCARE/WORK RELATED CHILD CARE COSTS (wkly amt x.) 9. OTHER EXPENSES (please specify) MONTHLY LOAN/CHARGE CARD EXP. (Do not incl. mo. Payments shown above.) Balance 0 NAME AND RELATIONSHIP OF ALL MEMBERS OF HOUSEHOLD WHOSE EXPENSES ARE INCLUDED: MONTHLY EXPENSES AND DEDUCTIONS FROM INCOME 6. RENT/MORTGAGE PAYMENTS (residence) 9. FOOD/HOUSEHOLD SUPPLIES/LAUNDRY/CLEANING. CLOTHING 6. AUTOMOBILE (loan payment) 8. AUTOMOBILE (repairs). TOTAL MO. EXP & DEDUCTIONS FROM INCOME (Total lines -) 5. AVERAGE WKLY EXP. & DEDUCTIONS (Total Mo. Exp. divided by.)
3 ASSETS Include all assets known to you, even if you do not know the value. Under ownership, H=Husband; W=Wife; J=Joint. Lien amount includes only those debts secured by the item, such as a mortgage against a home, debts shown on title to vehicle loans against life insurance policies or loans where an item is pledged as collateral. Value assets as of date of Petition for Dissolution of Marriage was filed. Show valuation date here: DESCRIPTION Value Mortgages Value (H/W/J) A. Household Furnishings, Furniture, Appliances. In Possession of Husband. In possession of Wife B. Automobiles, Trucks, Rec. Vehicles (make/model/year) C. Securities-Stocks, Bonds & Stock Options D. Cash, Checking, Savings, Deposit Accts, CD's, (incl. Bank/Cr. Union name and type of account) E. Real Estate (incl. Land Sales Contracts. Marital Residence (Show Address) Basis of Valuation Lender Name st Mtg Lender Name st Mtg. Other (Show Address) Basis of Valuation Lender Name st Mtg Lender Name nd Mtg
4 DESCRIPTION F. Cash Retirement Accts (IRAs, SEPS Keoughs, 0K, Employee Savings, Plan, Stock Ownership/Profit Sharing, etc.) Value Mortgages Value (H/W/J) G. Retirement Benefits, Deferred Compensation Plans and Pensions (include infor available on benefits, whether benefits were vested in pay status) H. Business Interests I. LIFE INSURANCE (Company name and death benefits) (Term and Group). Named Beneficiary. Named Beneficiary Named Beneficiary (Whole Life & Others) (Cash Value under Gross Value). Named Beneficiary. Named Beneficiary. Named Beneficiary J. Other Assets ) (incl. any type of assets that have value, incl. jewelry, pers. property,. assets located in safety dep. Boxes, accrued bonuses, etc. 5 6
5 D. ASSETS ACQUIRED BY YOU PRIOR TO THE MARRIAGE OR THROUGH INHERITANCE OR GIFT (Whether now owned or not) SHOW SIGNIFICANT ASSETS ONLY Value Mortgages Value (H/W/J) A. Assets Owned by You Prior to Marriage (Value as of date of marriage) 5 6 B. Assets Acquired by You During Your Marriage Through Gifts or Inheritance (value as of date of marriage) I affirm under penalty of perjury that the foregoing, including any attachments, is true and correct. That this declaration was executed on this day of, 0. I understand that I am under a duty to supplement or amend this Financial Declaration prior to trial if I learn the information provided is incorrect or the information provided is no longer true. Signature CERTIFICATE OF SERVICE I hereby certify that a true, exact and authentic copy of the foregoing has been served by United States mail, first class postage prepaid, this day of, 0, upon the following: RUPPERT & SCHAEFER 90 E. 96th Street, Suite D Indianapolis, IN 60 Telephone: 7/
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