FINANCIAL DECLARATION PERSONAL INFORMATION Name: ____________________________________DOB___________ CASE #________________ Marital Status: Single Married Divorced Separated Number of dependents: _________________________ Court ordered child support: $____________ EMPLOYMENT Are you currently employed? Yes No How long have you been unemployed: _____________ Employer: __________________________ How long:__________ Monthly income: $_____ _______ Spouse's employer: __________________ How long:__________ Monthly income: $_____________ OTHER MONTHLY INCOME Unemployment Disability Retirement Child Support Spousal Support $ General Relief $ Social Security $ SSI $ AFDC $ $ Other $ $ $ $ HOUSING: Renting Buying Your share of the monthly payment: $ __________________ With whom do you reside? ___________________________________________________________ MOTOR VEHICLES (Including motocycles, boats motor homes, trailers, etc.) Year & Make _______________________ Own Lease Year & Make _______________________ Own Lease CREDITORS (VISA, department stores, medical bills, etc.) Creditor _____________________________________ Creditor _____________________________________ Creditor _____________________________________ ASSETS IMPORTANT: Each of the questions about assets must be answered. If the answer is $0.00 then indicate as such. Do not leave any of the lines blank. Monthly payment: $ ______________ Monthly payment: $ ______________ Monthly payment $_________________ Monthly payment $_________________ Monthly payment $_________________ Checking Account Balance Savings Account Balance Money owed to you Equity in property you own Other assets $____________________ $____________________ $____________________ $____________________ $____________________ I declare under the penalty of perjury under the laws of the state of California that the foregoing is true and correct. Dated:_________________ Signed:____________________________ American LegalNet, Inc. www.FormsWorkFlow.com