Page 1 of 5 DR-250 ()(cs)FINANCIAL DECLARATION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) CASE NO. ) ) FINANCIAL DECLARATION OF PARTY A PARTY B Date of Marriage: Date of Separation: (Divorce/dissolution cases only)Party A: Date of Birth: Age: Occupation: Present Employer and Employer's Address: How long at this job? If you are employed, but expecting soon to become unemployed or change jobs, describe the change you expect, why and how it will affect your income. If currently unemployed, describe your efforts to find employment, how soon you expect to be employed and the pay you expect to receive. Party B: Date of Birth: Age: Occupation: Present Employer and Employer's Address: How long at this job? If you are employed, but expecting soon to become unemployed or change jobs, describe the change you expect, why and how it will affect your income. If currently unemployed, describe your efforts to find employment, how soon you expect to be employed and the pay you expect to receive. Party A: Party B: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 DR-250 ()(cs) FINANCIAL DECLARATION PART A. INCOME AND EXPENSE STATEMENT Party A Party B 1. Gross from: Salary and wages (incl. commissions, bonuses and overtime) payable $ $ weekly/monthly/etc. Pensions and retirement .............................. $ $ Social Security ............................................. $ $ Disability and unemployment insurance ....... $ $ $ $ $ $ Welfare/Alaska Temp. Assistance payments Child/spousal support from prior Dividends and interest (including Corporation dividends $ $ Rents ........................................................... $ $ All other sources: (Specify) $ $ $ $ $ $ Total Monthly Income ......... $ $ 2. Itemize from gross income: Income taxes ............................................... $ $ Social Security ............................................. $ $ Medicare Tax ............................................... $ $ Unemployment insurance ............................ $ $ Medical or other insurance ........................... $ $ Union or other dues ..................................... $ $ Retirement or pension fund .......................... $ $ Savings plan ................................................ $ $ Other: (Specify) $ $ $ $ $ $ Total Deductions ................ $ $ 3.Net monthly income ..............................................$ $ 4.Total monthly expenses: (specify which party is presently the custodial parent of anychildren of this marriage and list name and relationship of all members of the householdwhose expenses are included) Party A: Party B: $ $ $ $ American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 DR-250 ()(cs)FINANCIAL DECLARATION 4.Total Monthly Expenses - ContinuedThe court may require proof of expenses in the form of canceled checks, receipts orother documents.Party A Party B Rent or mortgage payments (residence) ....................... $ $ Real Property taxes (residence) .................................... $ $ Maintenance (residence) ............................................... $ $ Food and household supplies ....................................... $ $ Utilities .......................................................................... $ $ Telephone ..................................................................... $ $ Laundry and cleaning .................................................... $ $ Clothing......................................................................... $ $ Medical ......................................................................... $ $ Dental ........................................................................... $ $ Insurance (life, health, accident, etc.) ............................ $ $ Child care ...................................................................... $ $ Child/spousal support payments from prior $ $ School ........................................................................... $ $ Entertainment ............................................................... $ $ Incidentals ..................................................................... $ $ Transportation ............................................................... $ $ Gas, oil, repair (auto) .................................................... $ $ Auto payments .............................................................. $ $ Installment payment(s) (Itemize below) Balance Creditor's Name For Due $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Other Monthly Expenses: (Specify) $ $ $ $ $ $ $ $ Total Expenses ............. $ $ 5.Other debts and obligations:Creditor's Name For Date Payable Balance Due Party A Party B $ $ $ $ $ $ $ $ $ $ Total Other Debts .......... $ $ Party A: Party B: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 DR-250 ()(cs)FINANCIAL DECLARATION 6.List the value of the following property belonging to the parties:Party A Party B Cash on hand ....................................................... $ $ Money in checking account(s) .............................. $ $ Money in credit union account(s) .......................... $ $ Money in any other account(s) or deposits ........... $ $ Retirement or pension fund .................................. $ $ Life insurance cash value ..................................... $ $ Value of any stocks & bonds ................................ $ $ Value of real estate .............................................. $ $ Value of all other property .................................... $ $ Total Property ............... $ $ There is no property subject to disposition by the court in this proceeding. All property otherwise subject to disposition by the court in this proceeding has been disposed of by written agreement of the parties or oral stipulation made in open court. The property subject to disposition by the court in this proceeding is: Value of Amount of Description of assets and obligations assets obligations $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Party A: Party B: NOTE: If this form is being filled out for a children's proceeding, omit Parts B and C, and complete Part D. PART B. PROPERTY STATEMENT (Divorce/dissolution cases only) American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 DR-250 ()(cs)FINANCIAL DECLARATION PART C. ATTORNEY FEES AND COST STATEMENT (Divorce/dissolution cases only) I have paid my attorney(s) $ for fees, and $ for costs, and my arrangement with my attorney for payment of fees and costs is as follows: Attorney's Signature Date Party's Signature Date PART D. HEALTH I do do not have a disease or defect in my health which will affect my ability to earn a living and support myself in the foreseeable future. (If you do have such a disease or defect, please explain below. Any claim of disability or impaired earning capacity must be supported by a doctor's statement attached as an exhibit to this statement.) SIGNATURES I swear (or affirm) that all the information given in this declaration is true. Date Signature of Declarant Type or Print Name Mailing Address City State Zip Work Phone Home Phone Subscribed and sworn to or affirmed before me at , Alaska, on . (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: Party A: Party B: American LegalNet, Inc. www.FormsWorkFlow.com