1 2 3 4 Code: 1740 Name: ______________________________ Address: ____________________________ ____________________________________ Telephone:___________________________ 5 IN THE FAMILY DIVISION 6 OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 7 IN AND FOR THE COUNTY OF WASHOE 8 9 10 11 12 13 __________________________________, ) Plaintiff/Petitioner ) ) vs ) ) __________________________________, ) Defendant/Respondent) ____________________________________) 16 STATE OF NEVADA ) ) County of ________________) 17 I, __________________________________, being duly sworn and under the penalties of (print your name) 18 19 Dept. No. ___________________ SHORT FORM FINANCIAL DECLARATION 14 15 Case No. ____________________ perjury, depose and state as follows: 20 I have read the contents of this Financial Declaration and am competent to testify as to the 21 22 contents, and the contents are true of my own knowledge except for those matters stated on 23 information and belief, and as to those matters, I believe them to be true. 24 _____________________________________ (Signature of Declarant) 25 Submitted by: 26 SUBSCRIBED and SWORN to before me 27 this _______day of ________________, 20______. 28 __________________________________________ NOTARY PUBLIC 03/29/05 _____________________________________ (Signature of Attorney) 1 American LegalNet, Inc. www.FormsWorkflow.com 1 MONTHLY INCOME 2 3 If you are presently unemployed, answer questions 1 – 2 and then go on to the rest of the questions. If you are employed, print “not applicable” in questions 1 – 2 and go on to the rest of the questions. 4 5 6 7 1. __________ I am presently unemployed and have been unemployed since _______________________________________ (date of your last employment) 8 9 10 2. My last employer was ________________________________________________ and I earned $__________________ per hour / week / month (circle one) 11 12 Answer all of the following questions. circumstances, print “N/A in the spaces. If the question is not applicable in your particular 13 Monthly Money Earned and Received 14 15 3. 16 I am employed and earn the following wages: I am paid by the hour and my hourly wage is: I work __________ hours per week. 17 18 $ __________________ I am paid (circle one) every week; every 2 weeks; 1x a month 2x a month and without anything being deducted from it, each check is for (attach last 3 paystubs): 20 21 22 $ _________________ I work overtime approximately __________ hours per month at the rate of $ _____________ per hour for an average monthly overtime earning of: 19 $ _________________ I receive commissions each month in the amount of: (averaged over a year) I receive tips each month in the amount of: (averaged over a year) I receive bonuses each month in the amount of: (averaged over a year) 23 24 25 26 Based upon the above information, My total average monthly income from employment is: 27 28 $ ________________ $ ________________ $ ________________ $________________ Income Other Than Wage Earnings 03/29/05 2 American LegalNet, Inc. www.FormsWorkflow.com 1 4. 2 3 5. 4 5 6. 6 7 7. 8 I receive child support each month from the other party in the amount of (amount of court order $_____________): $ ________________ I receive child support each month from someone else in the amount of (amount of court order $_____________): $_________________ I receive alimony/spousal support each month from the other party in the amount of (amount of court order $_____________): $ ________________ I receive alimony/spousal support each month from someone else in the amount of (amount of court order $_____________) : $_________________ 9 10 8. I receive the following government assistance: I receive Social Security Benefits each month in the amount of: I receive Non Social Security Disability each month in the amount of: I receive State or County assistance (welfare, TANF, SIIS, etc.) each month in the amount of: I receive unemployment each month in the amount of: 11 12 13 14 $ ________________ $ _________________ $ ________________ $ ________________ 15 9. I receive retirement benefits each month in the amount of: $ ________________ 16 10. I receive investment income each month in the amount of: $ ________________ 11. I receive income from rental properties (excluding depreciation) each month in the amount of: $ _________________ I live with someone (friend, relative, significant other) who contributes to the living expenses each month in the amount of: $ _________________ 17 18 19 12. 20 21 13. I am receiving educational or school benefits in the amount of: $ _________________ 22 14. I am receiving money from friends, relatives, others each month in the amount of: $ __________________ I am receiving other sources of income, including but not limited to monthly distributions from a trust or will in the amount of: $ __________________ 23 24 15. 25 26 27 28 MY TOTAL MONTHLY INCOME FROM ALL SOURCES IS: $ __________________ (this amount is your “gross income”) HOW MUCH IS BEING WITHHELD FROM YOUR INCOME EACH MONTH? 03/29/05 3 American LegalNet, Inc. www.FormsWorkflow.com 1 Federal income taxes: $ _______________ Social Security $ _______________ Medicare taxes $ _______________ 5 Child support for children with the other party $ _______________ 6 Child support for children with someone else 7 Alimony/spousal support paid to the other party $_________________ Alimony/spousal support paid to someone else: $_________________ Retirement, 401K, etc. $ _________________ 2 3 4 8 $________________ 9 10 Health insurance total: Of this amount, $__________ is the amount paid for your and the other party’s children. 11 12 13 $_________________ 14 Any other garnishments or withholdings, please list: 15 _________________________________ $ __________________ 16 _________________________________ $ __________________ _________________________________ $ __________________ 17 18 19 TOTAL WITHHOLDING FROM PAYCHECK: $ __________________ 20 YOUR TOTAL EXPENSES EACH MONTH (REPORT ONLY THE AMOUNT YOU ACTUALLY PAY) 21 22 23 1. Each month I pay rent or mortgage or I contribute to the rent or mortgage where I live in the amount of: $ _________________ For food each month, I spend or contribute to the family with whom I am living the amount of: $ _________________ 24 25 26 2. 3. For house/apartment utilities (gas, power, water, garbage, sewer) I pay or contribute to my household the amount of: $ _________________ 4. Life insurance 5. I have a vehicle and pay the following each month: 27 28 03/29/05 $_________________ 4 American LegalNet, Inc. www.FormsWorkflow.com 1 Vehicle payment each month in the amount of: Fuel for the vehicle in the amount of: Insurance for the vehicle (if paid over a period of six months or a year, average the payment out) Repairs and maintenance (averaged over a year) 2 3 4 $ ________________ $ ________________ I do not own a vehicle but my monthly transportation costs (bus, taxi, etc.) are: $ _________________ 7. I have medical bills that I pay on each month in the amount of: $ ________________ 8 8. I have medical prescriptions each month in the amount of: $ _________________ 9 9. I pay health insurance (not deducted from my check) in the amount of: $ _________________ I am paying child support each month that is not deducted directly from my paycheck in the amount of (amount of court order $_____________): $ _________________ I am also legally responsible for the support of others, namely: _________________________________________________ each month in the amount of (amount of court order $_____________): $_________________ 12. Each month I pay child care in the amount of: $ _________________ 13. I have credit card /charge account payments each month and pay those charges as follows: Name of Credit Card or Charge Account 5 6. $ _________________ $ ________________ 6 7 10 11 10. 12 13 11. 14 15 16 17 18 19 20 ________________________________________in the amount of: $ ________________ 21 ________________________________________in the amount of: $ _________________ 22 ________________________________________in the amount of $ _________________ 23 ________________________________________in the amount of $ __________________ 24 ________________________________________in the amount of $ __________________ 25 ________________________________________in the amount of $ __________________ 26 27 28 14. Clothing, cleaning, laundry, etc. each month: $ _________________ 15. I have school or educational expenses each month of: $ _________________ 03/29/05 5 American LegalNet, Inc. www.FormsWorkflow.com 1 2 16. My recreational expenses each month are: $ _________________ 3 17. My charitable expenses each month are: $_________________ 4 18. 5 Other expenses not listed above, please list: _____________________________________________ $ _________________ 6 _____________________________________________ $ _________________ 7 _____________________________________________ $ _________________ TOTAL MONTHLY EXPENSES: $ _________________ NET INCOME (DEFICIT) EACH MONTH (TOTAL MONTHLY INCOME MINUS TOTAL WITHHOLDING MINUS TOTAL MONTHLY EXPENSES): $_________________ 8 9 10 11 12 ASSETS AND DEBTS 13 14 In the following section, list ALL assets and debts you have, either separately or jointly with the other party. 15 16 17 1. House/Mobile Home (circle one) Separate/Community/Joint (circle one) Who has possession? (circle one) me/the other party 18 a. How much it is worth: 20 $ ___________________ b. How much you owe on it: 19 $ _________________ 21 2. 22 Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession 23 Checking Accounts: _____________________________________________ $ __________________ _________________________________________________________ $ __________________ 26 _________________________________________________________ $ __________________ 27 3. 28 Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession: 24 25 Savings Accounts: _________________________________________________________ 03/29/05 $ __________________ 6 American LegalNet, Inc. www.FormsWorkflow.com 1 2 _________________________________________________________ $ __________________ 3 _________________________________________________________ $ _________________ 4 4. Cash you have on hand: $ __________________ 5. Retirement Accounts (indicate in whose name accounts are held) 5 6 _________________________________________________________ $ __________________ 8 _________________________________________________________ $ _________________ 9 _________________________________________________________ $ ___________________ 10 _________________________________________________________ $ __________________ 7 11 12 6. Vehicles: (list ALL vehicles owned by you and/or the other party, even if your name is not on the registration and include such things as motorcycles, boats and recreational vehicles) 13 a. 14 Make and model:_________________________________ What you owe on the vehicle: $ ___________________ What the vehicle is worth: $ _________________ 15 16 b. 17 Make and model: _________________________________ 18 What you owe on the vehicle: $ ___________________ 19 What the vehicle is worth: $ ___________________ 20 c. Make and model: _________________________________ 21 What you owe on the vehicle: 23 $ _________________ What the vehicle is worth: 22 $ _________________ 24 25 7. Stocks and bonds: $_________________ 8. Credit Cards and Store Charge Accounts: 26 27 28 Name of Account ______________________________ 03/29/05 Balance $_________________ Minimum Monthly Payment $ __________________ 7 American LegalNet, Inc. www.FormsWorkflow.com 1 2 _______________________________ $ _________________ $ __________________ 3 _______________________________ $ _________________ $ ___________________ 4 _______________________________ $ _________________ $ __________________ _______________________________ $ _________________ $ __________________ 5 6 7 8 9 On the lines below, please list any other assets worth more than $500.00 or debts you have that have not been previously listed. Assets such as furniture, jewelry, boats, assets held in your child’s name or joint tenancy with any other person, and personal loans owed to you. Debts such as medical bills and personal loans owed to others. 10 11 Asset Value of Asset ___________________________________________ $ _________________ ___________________________________________ $ __________________ ___________________________________________ $ _________________ 12 13 14 Debt 15 16 Balance Owed on Debt ___________________________________________ $ __________________ ___________________________________________ $ _________________ ___________________________________________ $ _________________ 20 ___________________________________________ $ ___________________ 21 ___________________________________________ $ __________________ 22 ___________________________________________ $ _________________ 17 18 19 23 24 25 26 27 28 ATTORNEY FEE ARRANGEMENT I have paid my attorney $______________________, including costs and expert fees, since this case began. I paid this amount from (source of funds used) _____________________________ I currently owe my attorney $ ______________________ in addition to the amount paid above. My fee arrangement is as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 03/29/05 8 American LegalNet, Inc. www.FormsWorkflow.com 1 SECOND JUDICIAL DISTRICT COURT COUNTY OF WASHOE, STATE OF NEVADA 2 3 AFFIRMATION Pursuant to NRS 239B.030 4 The undersigned does hereby affirm that the preceding document, 5 6 7 (Title of Document) 8 9 filed in case number: 10 Document does not contain the social security number of any person 11 -OR- 12 Document contains the social security number of a person as required by: 13 A specific state or federal law, to wit: 14 ______________________________________________________ (State specific state or federal law) 15 16 -or- 17 For the administration of a public program 18 -or- 19 For an application for a federal or state grant 20 -or- 21 Confidential Family Court Information Sheet (NRS 125.130, NRS 125.230 and NRS 125B.055) 22 23 24 Date: (Signature) 25 26 (Print Name) 27 28 (Attorney for) Affirmation Revised December 15, 2006 American LegalNet, Inc. www.FormsWorkflow.com