FINANCIAL DECLARATION FORM
STATE OF INDIANA: CIRCUIT AND SUPERIOR COURTS
OF PORTER COUNTY
IN RE THE MARRIAGE OF: |
Cause Number: |
Petitioner,
And
Respondent
In accordance with Local Rule 18 of the Porter Superior Court and Indiana Trial Rules 26, 33, 34, 35 and 37, the undersigned, Petitioner or Respondent, hereby submits the following
VERIFIED FINANCIAL DISCLOSURE STATEMENT:
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FINANCIAL DECLARATION OF |
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Dated: |
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I. PRELIMINARY INFORMATION: |
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Husband: |
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Wife: |
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Address: |
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Address: |
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Soc. Sec. No.: |
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Soc. Sec No.: |
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Badge/Payroll No.: |
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Badge/Payroll No.: |
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Occupation: |
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Occupation: |
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Employer: |
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Employer: |
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Birth Date: |
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Birth Date: |
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Date of Marriage: |
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Date of Physical Separation: |
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Date of Filing: |
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Children: |
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Name: |
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Age: |
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DOB: |
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SSN: |
Name: |
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Age: |
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DOB: |
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SSN: |
Name: |
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Age: |
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DOB: |
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SSN: |
II. HEALTH INSURANCE INFORMATION:
Name and Address of health care insurance company:
Name all persons covered under plan(s):
Weekly cost of total health insurance premium:
Weekly cost of health insurance premium for children only:
Name of the children’s health care providers:
The names of the schools and grade level for each child are:
List any extraordinary health care concerns of any family member:
List any educational concerns of any family member:
III.INCOME INFORMATION:
A.EMPLOYMENT HISTORY:
Current Employer:
Address:
Telephone No.: |
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Length of Employment: |
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Job Description: |
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Gross Income: |
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Per week |
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Bi-weekly |
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Per month |
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Yearly |
Net Income: |
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Per week |
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Bi-weekly |
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Per month |
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Yearly |
B.EMPLOYMENT HISTORY FOR LAST 5 YEARS:
Employer |
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Dates of Employment |
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Compensation (per wk/mo/yr) |
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C.INCOME SUMMARY:
1.GROSS WEEKLY INCOME from: Salary and wages, including commissions, bonuses, allowances, and over-time
Note: If paid monthly, determine weekly income by dividing monthly income by 4.3
Pensions & Retirement
Social Security
Disability and unemployment insurance
Public Assistance (welfare, AFDC payments, etc.)
Food Stamps
Child supports received for any child(ren) not both of the parties to this marriage
Dividends and Interest
Rents received
All other sources (specify)
TOTAL GROSS WEEKLY INCOME
2.ITEMIZED WEEKLY DEDUCTIONS: from gross income
State and Federal Income Taxes:
Social Security & Medicare Taxes:
Medical Insurance |
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Coverage: |
Health |
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Dental |
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Eye Care |
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Psychiatric |
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Union or other dues:
Retirement:
Pension fund: Mandatory ( )Optional ( )
Profit sharing: Mandatory ( )Optional( )
401(K): Mandatory ( ) Optional ( )
SEP: Mandatory ( ) Optional ( )
ESOP: Mandatory ( ) Optional ( )
IRA: Mandatory ( ) Optional ( )
403 B: Mandatory ( ) Optional ( )
Child Support withheld from pay (not including this case)
Garnishments (itemize on separate sheet)
Credit Union debts
Direct Withdrawals Out of Paychecks:
Car Payments
Life Insurance
Disability Insurance
Thrift plans
Credit Union Savings
Bonds
Donations
Other (specify)
Other (specify)
TOTAL WEEKLY DEDUCTIONS:
3. WEEKLY DISPOSABLE INCOME:
(A minus B: Subtract Total Weekly Deduction from Total Weekly Gross Income)
IN ALL CASES INVOLVING CHILD SUPPORT: Prepare and attach an Indiana Child Support Guideline Worksheet (with documentation verifying your income); or, supplement with such a Worksheet within ten (10) days of the exchange of this Form.
IV. MONTHLY LIVING EXPENSES:
House
1.Rent (Mortgage)
2.2nd Mortgage
3.Line of Credit
4.Gas/Electric
5.Telephone
6.Water
7.Sewer
8.Sanitation (garbage)
9.Cable
10.Satellite
11.Internet
12.Taxes (real estate – if not included in mortgage payment
13.Insurance (house – if not included in mortgage payment)
14.Lawn Care/Snow Removal
Groceries
1.Food
2.Toiletries
3.Cleaning Products
4.Paper Products
Clothing
1.Clothes
2.Shoes
3.Uniforms
Health Care
1.Health Insurance not deducted from pay
2.Dental Insurance not deducted from pay
3.Doctor visits (non-insurance covered)
4.Dental visits (non-insurance covered)
5.Prescription Pharmaceutical (non-insurance covered)
6.Over-the-counter medicine
7.Glass/contact lenses
8.Other non-insurance covered health care (itemize)
Car & Travel
1.Car Payment
2.Gasoline
3.Oil/Maintenance
4.Insurance (car)
5.Car Wash
6.Tolls
7.Train/Bus
8.Parking Lot Fees
9.License Plates
Beauty Care
1.Hair Dress/Barber
2.Cosmetics
School Needs
1.Lunches
2.Books
3.Tuition/Registration
4.Uniforms
5.School Supplies
6.Extra-Curricular Activities
Infant Care
1.Diapers
2.Baby Food
Miscellaneous
1.Church Donations
2.Charitable Donations
3.Life Insurance
4.Babysitter
5.Newspapers & Magazines
6.Cigarettes
7.Dry Cleaning
8.Entertainment
9.Cell Phone
10.Dues/Subscriptions
11.Charge Cards
12.Other (specify)
SUB-TOTAL OF EXPENSES:
Average Weekly Expenses (multiply monthly expenses by 12 and divide by 52)
V. PROVISIONAL ARREARAGE COMPUTATIONS:
If you allege the existence of a child support, maintenance, or other arrearage, attach all records or other exhibits regarding the payment history and complete the child support arrearage.
You must attach a Child Support Guideline Worksheet to your Financial Declaration Form or one must be exchanged with the opposing party/counsel within 10 days of receipt of the other parties= Financial Declaration Form.
ASSETS
All property is to be listed regardless of whether it is titled in your name only or jointly of if the property you own is being held for you in the name of a third party.
VI. PROPERTY:
A. MARITAL RESIDENCE:
Description:
Location:
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Date Acquired: |
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Titled: |
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Purchase Price: |
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Down Payment: |
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Source of down payment: |
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Current Indebtedness: |
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Monthly Payment: |
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Current Market Value: |
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B.OTHER REAL PROPERTY: (Complete B on a separate sheet of paper for each additional parcel of real estate owned etc.)
Description:
Location:
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Date Acquired: |
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Titled: |
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Purchase Price: |
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Down Payment: |
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Source of down payment: |
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Current Indebtedness: |
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Monthly Payment: |
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Current Market Value: |
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C.PERSONAL PROPERTY: (motor vehicles, boats, motorcycles, furnishings, household goods, jewelry, firearms, etc. Household furnishings and household goods such as pots and pans need not
be itemized).
Type of Account
(Checking, Savings,
CD’s, etc.)
Balance on Date of Filing
VIII. NON-RETIREMENT SECURITIES: (stocks, bonds, mutual funds, etc.)
Type of Account
(Money Mkt, Stocks,
Bonds, Mutual Funds)
IX. LIFE INSURANCE POLICIES (whole life, variable life, annuities, term)
X.RETIREMENT ACCOUNTS (Pension, Profit Sharing, 401(K), SEP, IRA, KEOGH, ESOP, etc.)
Value as of date of filing
XI. OTHER PROFESSIONAL OR BUSINESS INTERESTS:
Type (Corp., Part., Sole Owner
XII. MARITAL BILLS, DEBTS, AND OBLIGATIONS: (list every single bill, debt and obligation regardless of whether the bill is title in your name, your spouse=s name, or jointly. Please include all mortgages, 2nd mortgages, home equity loans, charge cards, other loans, credit union loans, car payments, and unpaid medical bills, etc. Do not include monthly expenses such as utilities that are paid in full every month).
Balance as of
Date of Filing
