IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI PLAINTIFF CAUSE NO. DEFENDANT FINANCIAL DECLARATION OF NAME: ADDRESS: DATE OF BIRTH:
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1 IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI _, PLAINTIFF VS. _, CAUSE NO. DEFENDANT _ FINANCIAL DECLARATION OF I. GENERAL INFORMATION: NAME: ADDRESS: DATE OF BIRTH: SOCIAL SECURITY NUMBER: OCCUPATION: EMPLOYER: ADDRESS: MINOR CHILDREN OF PARTIES: Name Date of Birth _ Page 1 of 11 * Note: This declaration must be filed with the Chancellor before or at the time of the hearing. Failure by either party to complete, present, and file this form as required will authorize the Court to accept the statement of the other party as the basis for its decision. Fill out for self and other party also, insofar as possible. Any false statement made hereon may be considered a fraud upon the Court.
2 II. STATEMENT OF INCOME, EXPENSES, ASSETS AND LIABILITIES *Attach copies of State and Federal Income Tax Returns for last two taxable years and wage statements from your employer for last eight (8) weeks. Gross Monthly Income Amount 1. Salary and wages, including commissions, bonuses, allowance, and overtime Note: To arrive at monthly income figure if paid weekly, multiply by 4.3; if paid bi-weekly, multiply by Pensions and retirement 3. Social Security 4. Disability and unemployment payments 5. Public Assistance (welfare, AFDC payments, etc.) 6. Child support from any prior order 7. Dividends and interest 8. Rental Income 9. All other Sources (specify below) 10. TOTAL MONTHLY INCOME $ Monthly Deductions from Gross Income Amount 1. State Income Taxes 2. Federal Income Taxes 3. Social Security 4. Mandatory Medical Insurance 5. Mandatory Retirement 6. Union or other dues 7. Medicare 8. Other 9. TOTAL MONTHLY DEDUCTIONS 10. ADJUSTED GROSS INCOME $ Other Payroll Deductions: 11. Medical or other Insurance which is voluntary 12. Union or other Dues 13. Retirement or pension which is mandatory Beneficiary: 14. Retirement or pension which is voluntary Beneficiary: 15. Credit Union 16. Other: Total Deductions Monthly $ NET MONTHLY INCOME - TAKE HOME PAY $ Page 2 of 11
3 III. EXPENSE STATEMENT A. Living Expenses as of: Expense Self Children 1. Rent/Mortgage 2. Real Property Taxes 3. Real Property Insurance 4. Maintenance (Residence) 5. Food/Household Supplies 6. Water, Sewer, Etc. 7. Electricity 8. Gas (Residence) 9. Telephone 10. Laundry & Cleaning 11. Clothing 12. Insurance (Not payroll deducted) 13. Medical Expenses/Pharmaceutical 14. Dental Expenses 15. Child Care 16. Children's Allowances 17. Payment of Alimony/Child Support Payments made to former spouse per decree 18. School Expenses 19. Entertainment 20. Incidentals & Miscellaneous 21. Transportation (other than vehicle) 22. Gasoline & oil (automobile) 23. Car repairs and Maintenance 24. Insurance (automobile) 25. Automobile payments 26. Church Donations 27. Charitable Donations 28. Newspaper/Magazines 29. Cable TV 30. Pet Expenses 31. Yard Expenses 32. Maid Page 3 of 11
4 33. Retirement 34. Pest Control 35. Dining Out TOTAL LIVING EXPENSES: $ 36. Installment Payments (Notes, loans, charge accounts, credit cards, promissory notes not previously listed) Creditor Monthly Payment Balance 37. Other Expenses TOTAL INSTALLMENT PAYMENTS: COMBINED TOTAL EXPENSES: $ Page 4 of 11
5 EXHIBIT B IV. STATEMENT OF ASSETS *All property of the parties known to me owned individually or jointly indicating who holds or how title held: (H) Husband; (W) Wife; (J) Joint (A) REAL ESTATE **List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under LIABILITIES. 1. Address: Names on Title: Original Cost: Mortgage Balance: Present Value: Other Liens: Basis of Valuation: Monthly Payments: To whom: Individual Contributions: 2. Address: Names on Title: Original Cost: Mortgage Balance: Present Value: Other Liens: Basis of Valuation: Monthly Payments: To whom: Individual Contributions: Page 5 of 11
6 (B) MOTOR VEHICLES Vehicle #1: Registered in Name of: Mileage: Value: Loan Balance: How Costs Paid: Vehicle #2: Registered in Name of: Mileage: Value: Loan Balance: How Costs Paid: Vehicle #3: Registered in Name of: Mileage: Value: Loan Balance: How Costs Paid: Vehicle #4: Registered in Name of: Mileage: Value: Loan Balance: How Costs Paid: Page 6 of 11
7 (C) OTHER PERSONAL PROPERTY(Home Computers, guns, lawn mowers, Tv's, jewelry, household furnishings, etc.) Items Value TOTAL VALUE:$ (D) CHECKING/SAVINGS ACCOUNT Name on Account Type of Account Balance TOTAL VALUE:$ (E) OTHER INVESTMENTS (IRA'S Stocks, mutual funds, pension plans, retirement, 401k, etc.) Name(s) on Account Type of Investment Balance TOTAL VALUE:$ Page 7 of 11
8 (F) LIFE INSURANCE (Exclude Children) Insured Company Face Amount Loans Cash Value Beneficiary (G) ALL OTHER ASSETS: Description Value TOTAL VALUE OF ALL ASSETS $ Page 8 of 11
9 V. STATEMENT OF LIABILITIES ** Include Mortgage, car loan, credit cards, personal loans. (Also include these on #36). Creditor Names on Account Balance Monthly Payment Who Pays TOTAL LIABILITIES: $ Page 9 of 11
10 ACKNOWLEDGMENT OF TRUTHFULNESS I, _, declare to the Court that the foregoing statements, exhibits, and attachments, are true and correct and that this declaration was executed on the day of,. Page 10 of 11
11 IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI, PLAINTIFF VS., CAUSE NO. DEFENDANT CERTIFICATE OF COMPLIANCE I, A. E. (Rusty) Harlow, do hereby certify that I have this date complied with Rule 8.05 of the Uniform Chancery Court Rules and that I have mailed and/or delivered a copy of a detailed written statement of actual income and expenses and assets and liabilities to the attorney for the opposing party or the opposing party. SO CERTIFIED on this the day of, HARLOW LAW FIRM, P.A Sunset Drive Suite 3 Grenada, MS (fax) BY: A. E. (Rusty) Harlow, MSB # 3089 Page 11 of 11
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