STATE OF SOUTH CAROLINA COUNTY OF Plaintiff vs Defendant Address Age Occupation Employer Employer Address Gross Monthly Income 1) Earnings (attach recent pay stubs) 2) Overtime 3) Social Security, VA Benefits Workers Comp or Disability (SSI) 4) Unemployment 5) Alimony/Child Support 6) Other (Specify) (Add lines 1-6) Total Amount: ) ) ) ) ) ) ) ) ) ) IN THE FAMILY COURT OF THE JUDICIAL CIRCUIT SHORT FORM FINANCIAL DECLARATION OF (FOR USE ONLY IN CHILD SUPPORT ENFORCEMENT AND WITH PETITION FOR ORDER OF PROTECTION) Docket No. Amount: Assets 1) Cash 2) Money in Bank accounts (Checking & Savings) 3) IRA/401K/Pensions 4) Other (Specify) (Add lines 1-4) Total Amount: Amount: Monthly Expenses (have proof of expenses available) 1) Rent/Mortgage 2) Utilities 3) Cell phone/Phone 4) Food 5) Child Support/Alimony (outside of this case) 6) Child Care 7) Car Payment 8) Car Operating Expenses (Insurance, gas, maintenance) 9) Clothing 10) Cable/Satellite TV/Internet 11) Medical/Dental/Vision Expenses (self) 12) Medical/Dental/Vision Expenses (child) 13) Medical/Dental/Vision Insurance (self) 14) Medical/Dental/Vision Insurance (child) 15) Credit Card/Loan Payments 16) Other (Specify) (Add lines 1-16) Total Amount: Amount: How many other biological children in the home? Name(s) and Date(s) of Birth Sworn to before me this _______ day of _____________________, 20____ _______________________________________ Notary Public for South Carolina My Commission Expires: __________________ ________________________________________ Signature SCCA 430S (2/2016) American LegalNet, Inc. www.FormsWorkFlow.com