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Financial Declaration Form. This is a Washington form and can be use in Domestic Relations Statewide.
Tags: Financial Declaration, DRPSCU 01.1550, Washington Statewide, Domestic Relations
Superior Court of Washington County of In re: No. Petitioner, and Respondent. Financial Declaration [ ] Petitioner [ ] Respondent (FNDCLR) Name: Date of Birth: I. Summary of Basic Information Declarant’s Total Monthly Net Income (from § 3.3 below) $ Declarant’s Total Monthly Household Expenses (from § 5.9 below) $ Declarant’s Total Monthly Debt Expenses (from § 5.11 below) $ Declarant’s Total Monthly Expenses (from § 5.12 below) $ Estimate of the other party’s gross monthly income (from § 3.1f below) $ [ ] unknown II. Personal Information 2.1 Occupation: 2.2 The highest year of education completed: 2.3 Are you presently employed? [ ] Yes [ ] No a. If yes: (1) Where do you work. Employer's name and address must be listed on the Confidential Information Form. Financial Declaration (FNDCLR) - Page 1 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) American LegalNet, Inc. www.USCourtForms.com (2) _______________________ (1) When did you last work (month/year)? _______________________ (2) (3) b. If no: When did you start work there (month/year)? What were your gross monthly earnings? Why are you presently unemployed? $ III. Income Information If child support is at issue, complete the Washington State Child Support Worksheet(s), skip Paragraphs 3.1 and 3.2. If maintenance, fees, costs or debts are at issue and child support is Not an issue this entire section should be completed. (Estimate of other party’s income information is optional.) 3.1 Gross Monthly Income If you are paid on a weekly basis, multiply your weekly gross pay by 4.3 to determine your monthly wages and salaries. If you are paid every two weeks, multiply your gross pay by 2.15. If you are paid twice monthly, multiply your gross pay by 2. If you are paid once a month, list that amount below. Name Name a. $ $ b. Interest and Dividend Income $ $ c. Business Income $ $ d. Spousal Maintenance Received From ____________________________ $ $ e. Other Income $ $ f. Total Gross Monthly Income (add lines 3.1a through 3.1e) $ $ g. 3.2 Wages and Salaries Actual Gross Income (Year-to-date) $ $ Monthly Deductions From Gross Income a. Income Taxes $ $ b. FICA/Self-employment Taxes $ $ c. State Industrial Insurance Deductions $ $ d. Mandatory Union/Professional Dues $ $ e. Pension Plan Payments $ $ f. Spousal Maintenance Paid $ $ g. Normal Business Expenses $ $ h. Total Deductions from Gross Income $ $ $ $ (add lines 3.2a through 3.2g) 3.3 Monthly Net Income (Line 3.1f minus line 3.2h or line 3 from the Child Support Worksheet(s).) Financial Declaration (FNDCLR) - Page 2 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) American LegalNet, Inc. www.USCourtForms.com 3.4 Miscellaneous Income a. Child support received from other relationships b. Other miscellaneous income (list source and amounts) $ __________________________________________ $ $ __________________________________________ $ $ __________________________________________ $ $ __________________________________________ $ c. $ $ Total Miscellaneous Income (add lines 3.4a through 3.4b) $ $ $ 3.5 Income of Other Adults in Household $ 3.6 If the income of either party is disputed, state monthly income you believe is correct and explain below: IV. Available Assets 4.1 Cash on hand $ 4.2 On deposit in banks $ 4.3 Stocks and bonds, cash value of life insurance $ 4.4 Other liquid assets: $ V. Monthly Expense Information Monthly expenses for myself and ____________ dependents are: (Expenses should be calculated for the future, after separation, based on the anticipated residential schedule for the children.) 5.1 Housing Rent, 1st mortgage or contract payments Installment payments for other mortgages or encumbrances $ Taxes & insurance (if not in monthly payment) $ Total Housing 5.2 $ $ Utilities Heat (gas & oil) $ Electricity $ Water, sewer, garbage Financial Declaration (FNDCLR) - Page 3 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) $ American LegalNet, Inc. www.USCourtForms.com Telephone Cable $ Other $ Total Utilities 5.3 $ $ Food and Supplies Food for ___________ persons Supplies (paper, tobacco, pets) $ Meals eaten out $ Other $ Total Food Supplies 5.4 $ $ Children Day Care/Babysitting Clothing $ Tuition (if any) $ Other child-related expenses $ Total Expenses Children 5.5 $ $ Transportation Vehicle payments or leases Vehicle insurance & license $ Vehicle gas, oil, ordinary maintenance $ Parking $ Other transportation expenses $ Total Transportation 5.6 $ $ Health Care (Omit if fully covered) Insurance Uninsured dental, orthodontic, medical, eye care expenses $ Other uninsured health expenses $ Total Health Care 5.7 $ $ Personal Expenses (Not including children) Clothing $ Hair care/personal care expenses $ Clubs and recreation Financial Declaration (FNDCLR) - Page 4 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) $ American LegalNet, Inc. www.USCourtForms.com Education Books, newspapers, magazines, photos $ Gifts $ Other $ Total Personal Expenses 5.8 $ $ Miscellaneous Expenses Life insurance (if not deducted from income) $ Other _____________________________________________ $ Other _____________________________________________ $ Total Miscellaneous Expenses $ 5.9 Total Household Expenses (The total of Paragraphs 5.1 through 5.8) $ 5.10 Installment Debts Included in Paragraphs 5.1 Through 5.8 Creditor 5.11 Description of Debt Balance Month of Last Payment Other Debts and Monthly Expenses not Included in Paragraphs 5.1 Through 5.8 Creditor Description of Debt Balance Month of Last Payment Amount of Monthly Payment $ $ $ $ $ $ $ Total Monthly Payments for Other Debts and Monthly Expenses 5.12 Total Expenses (Add Paragraphs 5.9 and 5.11) $ $ Financial Declaration (FNDCLR) - Page 5 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) American LegalNet, Inc. www.USCourtForms.com VI. Attorney Fees 6.1 Amount paid for attorney fees and costs to date: 6.2 The source of this money was: 6.3 Fees and costs incurred to date: 6.4 Arrangements for attorney fees and costs are: 6.5 $ Other: $ I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at ________________________, [City] _________ [State] on ____________________ [Date]. Signature of Declarant Print or Type Name The following financial records are being provided to the other party and filed separately with the court. Financial records pertaining to myself: [ ] Individual [ ] Partnership or Corporate Income Tax returns for the years _____________ ______________________________________________including all W-2s and schedules; [ ] Pay stubs for the dates of ______________________________________________________ __________________________________________________________________________. [ ] Other: . Do not attach these financial records to the financial declaration. These financial records should be served on the other party and filed with the court separately using the sealed financial source documents cover sheet (WPF DRPSCU 09.0220). If filed separately using the cover sheet, the records will be sealed to protect your privacy (although they will be available to all parties in the case, their attorneys, court personnel and certain state agencies and boards.) See GR 22 (C)(2). Financial Declaration (FNDCLR) - Page 6 of 6 WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1) American LegalNet, Inc. www.USCourtForms.com