IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA. In Re: The Marriage / Children of: Civil Action No. ____________  _________________________, and _________________________. Petitioner Respondent _________________________ _________________________ _________________________ _________________________ Address Address _________________________ _________________________ Daytime phone Daytime phone FINANCIAL STATEMENT This form MUST be completed in ALL DIVORCE, CHILD SUPPORT, AND PATERNITY CASES. The Petitioner and the Respondent must each complete one of these forms. The completed form MUST be filed in the Circuit Clerks Office and served on the opposing party AT LEAST 5 DAYS BEFORE THE FIRST HEARING. If the Bureau For Child Support Enforcement is a party, the completed form must also be served on their local office. If your case involves minor children, or either party requests spousal support, you MUST file the following information WITH your completed Financial Statement. 1. A copy of your most recent wage or salary stub showing gross pay, deductions for taxes and other items, and net pay for a normal pay period, and for the year-to-date; 2. Copies of the your and your spouses complete income tax returns for the two years immediately preceding the date the petition was filed, together with copies of the f ederal Form W-2 for those years; and a copy of the Form W-2 for the most recent year for which that form is available, even if a tax return has not yet been filed for that year; 3. For self-employed persons and business owners, a copy of a current financial statement showing gross income, expenses, and net income; 4. Copies of any invoices or receipts showing the cost of any extraordinary medical expenses for the party or the children, of any child care expenses, and of any expenses n ecessitated by the special needs of the children. If the information you provide in this form, or file with this form changes after you file the form, you MUST immediately provide the new information. The information you provide on this form is ONLY for the use in the judi cial system, and is required by law and court rule to be kept CONFIDENTIAL. SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 1 of 9 >>>> 2Read each question carefully. Provide all requested information. Write or print clearly. After you have completed the form, you MUST sign the Verification on the last page before a Notary Public. Full Name: ____________________________________ Social Security No: _________________ Address: ___________________________________________________ Phone # : _____________  Any physical or mntal disability: _____________________________________________________e Age: ____ Education: _____________________________________________________________ _ Employer: __________________________________ Type of work: ________________________ Employment Address: ___________________________________________ Phone #: ______ ______ Date Employed: ______________________ per pay period: _____________________ Gross pay  Paid: ___ Weekly ___ Every two weeks ___ Twice a Month ___ Monthly Do you receive TANF benefits? ______ If Yes, list monthly amount: ___________________ YOUR INCOME : You MUST attach written documentation for all incom. For wage earning eme ployeeswho work fluctuating hours and/or overtime, provide wage history of at least six months, or length of most recent employment, whichever is less. Wage / salary history MUST be documented by W-2 forms, and/or year-to-date figures on the most recent pay stubs. For self-employed individuals, income MUST be verified by documents which show gross income and expenses. Income Source Monthly Amount 1. Salary 2. Wages 3. Commissions 4. Bonuses 5. Tips 6. Payments from a pension plan 7. Social Security, SSI 8. Other; explain SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 2 of 9 >>>> 3 PROPERTY List ALL property in which you, and / or your spouse have an interest. In the Who owns? column, put M for marital property; H if separate property of husband; W if separate property of wife. Property Description Market Value Amount Owed Who owns? Marital Home $_________ $_________ _________ Other Real Estate $_________ $_________ _________ Mobile Home $_________ $_________ _________ Motor Vehicles $_________ $_________ _________ ____________ $_________ $_________ _________ ____________ $_________ $_________ _________ Household Goods $_________ $_________ _________ Checking Accts. $_________ $_________ _________ Savings Accts. / CDs $_________ $________ _________ Money Market Certificates $_________ $_________ _________ Stocks $_________ $_________ _________ Credit Union Accts. $_________ $_________ _________ Profit Sharing Plans $_________ $_________ _________ Trusts $_________ $_________ _________ Stocks / Mutual Funds $_________ $_________ _________ Bonds $_________ $_________ _________ Pension Plans $_________ $_________ _________ IRA / SEP Accts. $_________ $_________ _________ Severance Pay; Unemployment $_________ $_________ _________ Workers Comp. $_________ $_________ _________ Whole life Insurance $_________ $_________ _________ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 3 of 9 >>>> 4Property Description Market Value Amount Owed Who owns? Annuities $_________ $_________ _________ Guns $_________ $_________ _________ Tools $_________ $_________ _________ Jewelry $_________ $_________ _________ Personal Property not located in Marital Home $_________ $_________ _________ Other*; __________________ $_________ $_________ _________ _________________________ $_________ $_________ _________ *Other includes, but is not limited to: coin collections; art; state and federal tax refunds; money owed to you or your spouse; business interests; money expected from a lawsuit or settlement; education benefits; patents; copyrights; royalties; contents of safe deposit boxes; and anything else of value. PROPERTY CONVEYED TO OTHERS List all real or personal property with a value of $500.00 or more that was sold, given away, or otherwise transferred by you and / or your spouse within the last 5 year s. Describe each such item; list market value when transferred; list type of transfer; provide name of the person to whom property was transferred; list amount received. ________________________________________________________________________ __________ _______________________________________________________