Total Monthly Income $ Miscellaneous Income Royalties, Trusts, and Other Investments $ Contributions from Others $ Dependent Children s monthly gross
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1 District Court Denver Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address): Case Number: COURT USE ONLY Phone Number: FAX Number: Atty. Reg. #: 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 ly 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. ly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.) Gross ly 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) Social Security Benefits (SSA) SSDI (Disability insurance entitlement program) SSI (supplemental income need based) Disability, Workers Compensation Interest & Dividends ly Income Miscellaneous Income Royalties, Trusts, and Other Investments Contributions from Others Dependent Children s monthly gross All other sources, i.e. personal injury income. Source of Income: settlement, non-reported income, etc. Rental Net Income Expense Accounts Child Support from Others Spousal/Partner Support from Others ly Miscellaneous Income Income 2017 Colorado Judicial Department for use in the Courts of Colorado Page 1 of 7
2 2. ly Deductions (Mandatory and Voluntary) Mandatory Deductions Federal Income Tax State/Local Income Tax PERA/Civil Service Social Security Tax Medicare Tax Mandatory Deductions Voluntary Deductions Life and Disability Insurance Stocks/Bonds Health, Dental, Vision Insurance Premium Retirement & Deferred Compensation number of people covered on Plan Child Care (deducted from salary) Flex Benefit Cafeteria Plan Deductions Voluntary ly Deductions 3. ly 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 1 st Mortgage 2 nd Mortgage Insurance (Home/Rental) & Property Condo/Homeowner s/maintenance Taxes (not included in mortgage Fees payment) Rent Housing B. Utilities and Miscellaneous Housing Services 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 Utilities and Miscellaneous Housing Services C. Food & Supplies Groceries & Supplies Dining Out Food & Supplies D. Health Care Costs (Co-pays, Premiums, etc.) 2017 Colorado Judicial Department for use in the Courts of Colorado Page 2 of 7
3 Doctor & Vision Care Dentist and Orthodontist Medicine & RX Drugs Therapist Premiums (if not paid by employer) Health Care E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) Primary Vehicle Payment Other Vehicle Payments Fuel, Parking, and Maintenance Insurance & Registration/Tax Payments (yearly amount(s) 12) Bus & Commuter Fees Transportation F. Children s Expenses and Activities Clothing & Shoes Child Care Extraordinary Expenses i.e. Special Misc. Expenses, i.e. Tutor, Books, Needs, etc. Activities, Fees, Lunch, etc. Tuition Children s Expenses and Activities G. Education for you - Please identify status: Full-time student Part-time student Tuition, Books, Supplies, Fees, etc. Education H. Maintenance (Spousal/Partner Support) & Child Support (that you pay) Maintenance Child Support This family This family Other family Other family Maintenance and Child Support I. Miscellaneous (Please list on-going expenses not covered in the sections above) 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 2017 Colorado Judicial Department for use in the Courts of Colorado Page 3 of 7
4 Miscellaneous I) ly Expenses (s from A 2017 Colorado Judicial Department for use in the Courts of Colorado Page 4 of 7
5 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, such as mortgages and car loans, because that 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/R = Co-Petitioner or Respondent, "J" = Joint. Name of Creditor Account Number (last 4- digits only) P C/R J Date of Balance Balance Unsecured Debt Balance Minimum ly Payment Required Reason for Which Debt was Incurred Minimum ly Payment SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES) Income (from Page 1) A ly Deductions (from Page 2) B ly Net Income (A minus B) ly Expenses (from Page 3) C Minimum ly Payment Required - Debts Unsecured (from Page 4) D ly Expenses and Payments (C plus D) Net Excess or Shortfall (ly Net Income less ly Expenses and Payments) (+/-) 2017 Colorado Judicial Department for use in the Courts of Colorado Page 5 of 7
6 5. Assets You MUST disclose all assets correctly. By indicating None, you are stating affirmatively that you or the other party, do not have assets in that category. Please attach additional copies of pages 5 & 6 to identify your assets, if necessary. If the parties are married or partners in a civil union, check under the heading Joint (J) all assets acquired during the marriage/civil union but not by gift or inheritance. Under the headings of Petitioner (P) or Co- Petitioner/Respondent (C/R), check assets owned before this marriage/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, list all of each party s assets under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R). "P" = Petitioner, "C/R = Co-Petitioner or Respondent, "J" = Joint. A. Real Estate (Address or Property Description and Name of Creditor/ Lender) B. Motor Vehicles & Recreation Vehicles Including Motorcycles, ATV s, Boats, etc.) (Year, Make, Model) (Name of Creditor/Lender) C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution) D. Life Insurance (Name of Company/Beneficiary) P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed P C/R J Type of Account Account # (last 4-digits only) P C/R J Type of Policy Face Amount of Policy Net Value/Equity (Value minus amount owed) Net Value/Equity (Value minus amount owed) Balance as of Today Cash Value today 2017 Colorado Judicial Department for use in the Courts of Colorado Page 6 of 7
7 E. Furniture, Household Goods, and Other Personal Property, i.e. Jewelry, Antiques, Collectibles, Artwork, Power Tools, etc. Identify Items and report in total. P C/R J Current Possession Held by Estimated P C/R J Value as of Today Value = what you could sell it for in its current condition. F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts If owned please attach JDF 1111-SS. G. Pension, Profit Sharing, or Retirement Funds If owned please attach JDF 1111-SS. H. Miscellaneous Assets If you own any of the assets identified below, please check the appropriate box and attach JDF 1111-SS to report the value. Business Interests Stock Options Money/Loans owed to you IRS Refunds due to you Country Club & Other Memberships Livestock, Crops, Farm Equipment Pending lawsuit or claim by you Accrued Paid Leave (sick, vacation, personal) Oil and Gas Rights Vacation Club Points Safety Deposit Box/Vault Trust Beneficiary Frequent Flyer Miles Education Accounts Health Savings Accounts Mineral and Water Rights Other - Other - Other - Other - I. Separate Property If owned please attach JDF 1111-SS to identify the property and to report the value. Value/Balance of All Assets (A I) By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. (Checking this box requires you to remove JDF number and copyright at the bottom of the form.) 2017 Colorado Judicial Department for use in the Courts of Colorado Page 7 of 7
8 I swear or affirm under oath that this Sworn Financial Statement, attached schedules, and mandatory disclosures contain a complete disclosure of my income, expenses, assets, and debt as of the date of my signature. I understand that if the information I have provided changes or needs to be updated before a final decree or order is issued by the Court, that I have a duty to provide the correct or updated information. I understand that this oath is made under penalty of perjury. I understand that if I have omitted or misstated any material information, intentionally or not, the Court will have the power to enter orders to address those matters, including the power to punish me for any statements made with the intent to defraud or mislead the Court or the other party. Date: Signature of Petitioner or Co-Petitioner/Respondent Subscribed and affirmed, or sworn to before me in the County of, State of, this day of, 20. My Commission Expires: Notary Public/Deputy Clerk CERTIFICATE OF SERVICE I certify that on (date) a true and accurate copy of the SWORN FINANCIAL STATEMENT was served on the other party by: Hand Delivery, E-filed, Faxed to this number:, or By placing it in the United States mail, postage pre-paid, and addressed to the following: To: Your signature 2017 Colorado Judicial Department for use in the Courts of Colorado Page 8 of 7
SWORN FINANCIAL STATEMENT
District Court Denver Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental Responsibilities concerning: Petitioner: and Co-Petitioner/Respondent: Attorney
Complete all highlighted areas of this form. If something does not apply, use N/A.
Complete all highlighted areas of this form. If something does not apply, use N/A. District Court Denver Juvenile Court Pueblo County, Colorado Court Address: 501 N. Elizabeth, Room 116 Pueblo, CO 81003
Complete all highlighted areas of this form. If something does not apply, use N/A.
Complete all highlighted areas of this form. If something does not apply, use N/A. District Court Denver Juvenile Court County, Colorado Court Address: In re: The Marriage of: The Civil Union of: Parental
Complete all highlighted areas of this form. If something does not apply, use N/A.
Complete all highlighted areas of this form. If something does not apply, use N/A. District Court Denver Juvenile Court Pueblo County, Colorado Court Address: 501 N. Elizabeth, Room 116 Pueblo, CO 81003
SSI (supplemental income - need based)
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