) ) COUNTY OF ______________________________ ) ) ) Plaintiff, ) vs. ) ) Defendant. ) HUSBAND/FATHER Address Age Occupation Employer Employer Address STATE OF SOUTH CAROLINA IN THE FAMILY COURT OF THE _____ JUDICIAL CIRCUIT FINANCIAL DECLARATION OF ______________________________ Docket No. ___________________________________ WIFE/MOTHER Address Age Occupation Employer Employer Address Gross Monthly Income Principal Earnings from Employment 1 Husband/Father Wife/Mother Overtime, Tips, Commission, Bonuses 2 Pensions, Retirement, and Annuities income Additional Employment income Social Security Benefits (SSA) and VA Benefits Disability and Worker's Compensation Benefits Unemployment and AFDC Spousal or Child Support (from other marriage/relationship) Dividends, Interest, Trust Income, and Capital Gains Rental Income and Business Profits Other (Specify): TOTAL GROSS MONTHLY INCOME Payroll Deductions from Monthly Income Federal Income Tax State Income Tax Social Security and Medicare Tax (FICA) Self-Employment Tax Health and Dental Insurance (Adult) Health and Dental Insurance (Child) Union Dues Voluntary Retirement Contribution (401(k), 457, IRA) Mandatory Retirement Contribution Savings Plan Other (Specify): TOTAL MONTHLY DEDUCTIONS NET MONTHLY INCOME 4 3 Husband/Father Wife/Mother SCCA 430 (12/2009) 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Estimate monthly expenses: (Specify which party is the custodial parent and list name and relationship of all members of household whose expenses are included. _________________________________________________________________________________ MONTHLY EXPENSES 5 Residential Rent Payment Note or Mortgage Payment on Residence(s) Food and Household Supplies 6 Utilities, Water, and Garbage Collection Telephone and Cellular Phone Medical, Dental and Disability Insurance Premiums (not deducted from paycheck) Life Insurance Premiums (not deducted from paycheck) Child Support (from other relationship) Work Related Day Care Spousal Support (from prior marriage) Auto Payment Auto Insurance, taxes, gasoline, and maintenance 7 SUBTOTAL: Husband/Father Wife/Mother Real Property Tax on Residence(s) Maintenance for household 8 Adult Clothing Children's Clothing 9 Cable Television, Satellite, and Internet/Online Services Laundry and Dry Cleaning 10 Medical and Dental Expenses (not paid by insurance) Prescriptions, Glasses, and Contacts (not paid by insurance) Children's incidental expenses 11 School lunches, supplies, field trips, and fees 12 Entertainment 13 Adult Incidental expenses 14 All Installment payments 15 Other (Specify): SUBTOTAL: TOTAL MONTHLY EXPENSES Installment Loan Payments Section Creditor For Monthly Payment Balance Owed by 16 SCCA 430 (12/2009) 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Other Debts and Obligations not payable in monthly installments Creditor For Date Payable Balance Owed by 16 Are you currently in Bankruptcy? YES NO YES NO Are any obligations listed above, including mortgage and note payments, in arrears? If yes, please list the obligations in arrears. ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ All Marital Property Known to Parties Assets Cash and Money in Checking Account(s) Money in Savings Account(s), Credit Union, Money Market, or Cert. of Dep. Value of Voluntary Retirement Account(s) Value of Pension Account Value of Publicly Held Stocks, Bonds, Securities, Mutual Funds Value of Privately Held Stocks and Other Business Value of Real Estate ­ Net of Mortgage Balances Value of All Other Property17 Husband/Father Wife/Mother Joint TOTAL ASSETS Any Non Marital Property Known to Parties Description of Asset Title Owner Date of Acquisition Source of Funds to Acquirer Estimate Present market Value If total assets are less than $300,000.00, sign and have notarized. If total assets are greater than $300,000.00, itemize assets by completing additional sections below and sign and have notarized. Financial Accounts Section18 Owner Name of Institution Type of Account Balance SCCA 430 (12/2009) 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Voluntary Retirement Accounts and Pension Accounts Section Type of Account Value Publicly Held Stocks, Bonds, Securities, Mutual Funds Section (Non-Retirement)19 Name of Company Number of Shares/Type of Account Value Real Estate Section20 Owner Address Value Mortgage Balance Mortgage Equity Other Property Section17 Owner Description of Asset Value Loan Balance Equity ___________________________________________ Signature Sworn to before me this_____ day of_____________________, 20_____. _________________________________ (SEAL) Notary Public for South Carolina My commission expires: ____________ Custodial Parent (if applicable): _______________________________________________________________ SCCA 430 (12/2009) 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 1. A recent paystub should be attached to the Financial Declaration. To compute Principal Earnings from Employment, first determine whether you are paid semi-monthly, biweekly, or weekly. If you are paid semi-monthly, multiply the gross amount of your pay check by two. If you are paid biweekly, multiply the gross amount of your pay check by 26 and then divide by 12. If you are paid weekly, multiply the amount of your paycheck by 52 and divide by twelve. Round to the nearest whole dollar. To compute Overtime, Tips, Commission, and/or Bonuses, take an average of your monthly earnings from overtime, tips, commission, bonuses, etc. from the past three years or the length of employment if employed less than three years (including this year). To compute State, Local, and Social Security Tax deductions, use the same formula used to compute principal earnings in endnote 1 above, or consult or have your attorney consult an accountant. Net monthly Income is equal to Total Gross Monthly Income minus Total Monthly Deductions. Do not include any expense in the Monthly Expenses section that has already been included in the Deductions from Gross Monthly Income on page one of the Declaration. Food Expense is to include the cost of groceries, toiletries, cleaning supplies, and casual eating out. Auto Expenses are to include gasoline, oil changes, tune-ups, tire replacement, maintenance, and related items. Maintenance for Household is