1 2 3 4 Code: Name: ______________________________ Address: ____________________________ ____________________________________ Telephone:___________________________ 5 6 IN THE _______________ JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 7 IN AND FOR THE COUNTY OF __________________ 8 9 10 11 12 13 __________________________________, ) Plaintiff/Petitioner ) ) vs ) ) __________________________________, ) Defendant/Respondent) ____________________________________) 14 Case No. ____________________ Dept. No. ___________________ SHORT FORM FINANCIAL DECLARATION 15 16 17 18 19 20 STATE OF NEVADA ) ) County of ________________) I, __________________________________, being duly sworn and under the penalties of (print your name) perjury, depose and state as follows: 21 I have read the contents of this Financial Declaration and am competent to testify as to the 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 25 26 27 28 SUBSCRIBED and SWORN to before me _____________________________________ (signature) this _______day of _____________________, 20____. ____________________________________________ NOTARY PUBLIC 1 American LegalNet, Inc. www.FormsWorkflow.com 1 MONTHLY INCOME 2 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. 3 4 5 1. __________ I am presently unemployed and have been unemployed since 6 _______________________________________ (date of your last employment) 7 8 2. My last employer was ________________________________________________ and I 9 earned $__________________ per hour / week / month (circle one) 10 Answer all of the following questions. circumstances, print “N/A in the spaces. 11 If the question is not applicable in your particular 12 Monthly Money Earned and Received 13 14 3. 15 I am employed and earn the following wages: I am paid by the hour and my hourly wage is: I work __________ hours per week. 16 $ __________________ 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): 18 19 20 $ _________________ I work overtime approximately __________ hours per month at the rate of $ _____________ per hour for an average monthly overtime earning of: 17 $ _________________ 21 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) Income Other Than Wage Earnings 22 23 24 25 26 27 4. I receive child support each month from the other party in the amount of (amount of court order $_____________): $ ________________ $ ________________ $ ________________ $ ________________ 28 2 American LegalNet, Inc. www.FormsWorkflow.com 1 5. I receive child support each month from someone else in the amount of (amount of court order $_____________): 3 4 5 7. 6 7 8 8. 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: $ ________________ 9. I receive retirement benefits each month in the amount of: $ ________________ 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: $ _________________ 13. I am receiving educational or school benefits in the amount of: $ _________________ 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: $ __________________ 10 11 12 14 $_________________ I receive the following government assistance: 9 13 $ ________________ I receive alimony/spousal support each month from someone else in the amount of (amount of court order $_____________) : 6. $_________________ I receive alimony/spousal support each month from the other party in the amount of (amount of court order $_____________): 2 $ _________________ $ ________________ $ ________________ 15 16 17 12. 18 19 20 21 22 23 15. 24 25 26 MY TOTAL MONTHLY INCOME FROM ALL SOURCES IS: (this amount is your “gross income”) $ __________________ 27 28 HOW MUCH IS BEING WITHHELD FROM YOUR INCOME EACH MONTH? 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 Alimony/spousal support paid to the other party $________________ $_________________ 8 Alimony/spousal support paid to someone else: $_________________ 9 Retirement, 401K, etc. $ _________________ $_________________ 12 Health insurance total: Of this amount, $__________ is the amount paid for your and the other party’s children. 13 Any other garnishments or withholdings, please list: 2 3 4 7 10 11 14 _________________________________ $ _______________ _________________________________ $ _______________ _________________________________ $ _______________ 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 27 28 $_________________ 4 American LegalNet, Inc. www.FormsWorkflow.com I have a vehicle and pay the following each month: 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) $ ________________ $ ________________ 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 1 5. 2 3 4 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 14. Clothing, cleaning, laundry, etc. each month: $ _________________ 28 15. I have school or educational expenses each month of: $ _________________ 5 American LegalNet, Inc. www.FormsWorkflow.com 1 2 16. My recreational expenses each month are: $ _________________ 17. My charitable expenses each month are: $_________________ 18. Other expenses not listed above, please list: _____________________________________________ $ _________________ _____________________________________________ $ _________________ _____________________________________________ $ _________________ TOTAL MONTHLY EXPENSES: $ _________________ NET INCOME (DEFICIT) EACH MONTH (TOTAL MONTHLY INCOME MINUS TOTAL WITHHOLDING MINUS TOTAL MONTHLY EXPENSES): $_________________ 3 4 5 6 7 8 9 10 11 12 ASSETS AND DEBTS 13 In the following section, list ALL assets and debts you have, either separately or jointly with the other party. 14 15 16 1. 17 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: $ ___________________ 19 b. How much you owe on it: $ _________________ 20 2. Checking Accounts: 21 22 Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession 23 _____________________________________________ $ __________________ 24 _________________________________________________________ $ __________________ 25 _________________________________________________________ $ __________________ 26 3. Savings Accounts: 27 28 Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession: _________________________________________________________ $ __________________ 6 American LegalNet, Inc. www.FormsWorkflow.com 1 _________________________________________________________ $ __________________ _________________________________________________________ $ _________________ 4. Cash you have on hand: $ __________________ 5 5. Retirement Accounts (indicate in whose name accounts are held) 6 _________________________________________________________ $ __________________ 7 _________________________________________________________ $ _________________ _________________________________________________________ $ ___________________ _________________________________________________________ $ __________________ 2 3 4 8 9 10 11 6. on Vehicles: (list ALL vehicles owned by you and/or the other party, even if your name is not 12 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 26 27 28 7. Stocks and bonds: $_________________ 8. Credit Cards and Store Charge Accounts: Name of Account Balance Minimum Monthly Payment ______________________________ $_________________ $ __________________ _______________________________ $ _________________ $ __________________ 7 American LegalNet, Inc. www.FormsWorkflow.com 1 2 _______________________________ $ _________________ $ ___________________ 3 _______________________________ $ _________________ $ __________________ 4 _______________________________ $ _________________ $ __________________ 5 6 7 On the lines below, please list any other assets 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. 8 9 10 11 Asset Value of Asset ___________________________________________ $ _________________ ___________________________________________ $ __________________ ___________________________________________ $ _________________ 12 13 14 Debt Balance Owed on Debt 15 ___________________________________________ $ __________________ 16 ___________________________________________ $ _________________ ___________________________________________ $ _________________ ___________________________________________ $ ___________________ 20 ___________________________________________ $ __________________ 21 ___________________________________________ $ _________________ 22 ___________________________________________ $ ___________________ ___________________________________________ $ __________________ 17 18 19 23 24 25 26 27 28 8 American LegalNet, Inc. www.FormsWorkflow.com