financial declaration form

financial declaration form

state of Indiana: circuit and superior courts

of lake and porter counties

IN RE THE MARRIAGE OF )

)

-and- )

)

CAUSE NO.:

FINANCIAL DECLARATION FORM OF: _____________________________ DATED:

Husband:	Wife:
Address:	Address:

Soc. Sec. No.:	Soc. Sec. No.:
Badge/Payroll No.:	Badge/Payroll No.:
Occupation:	Occupation:
Employer:	Employer:
Birth Date:	Birth Date:

DATE OF MARRIAGE:

DATE OF PHYSICAL SEPARATION:

DATE OF FILING:

Names and dates of birth of all children of this relationship, whether by birth or adoption:

NOTE: THIS DECLARATION IS CONSIDERED MANDATORY DISCOVERY AND MUST BE EXCHANGED BETWEEN THE PARTIES WITHIN THE TIME PRESCRIBED BY THE LAKE AND PORTER COUNTY RULES OF FAMILY LAW. PARTIES NOT REPRESENTED BY COUNSEL ARE REQUIRED TO COMPLY WITH THESE PRACTICES. FAILURE BY EITHER PARTY TO COMPLETE AND EXCHANGE THIS FORM AS REQUIRED, WILL AUTHORIZE THE COURT TO IMPOSE THE SANCTIONS SET FORTH IN PARAGRAPH V OF THE LAKE COUNTY RULES OF FAMILY LAW.

* In paternity actions, the term "husband" includes the putative father, and the term "wife" includes the mother.

PART I. INCOME AND EXPENSES STATEMENT

STATEMENT OF INCOME, EXPENSES, ASSETS, AND LIABILITIES.

Attach copies of State and Federal Income Tax Returns for the last three (3) taxable years, and wage statements from your employer for the last eight (8) weeks.

Note: Attach separate sheets for subparts A, B, and C for current spouse(s), roommate(s), or other(s) residing in the home.

A. GROSS WEEKLY INCOME

from: Salary and Wages, including

commissions, bonuses, allowances

and overtime, payable

(pay period)

HUSBAND

WIFE

Note: If paid monthly, determine

weekly income by dividing monthly

income by 4.3

Pension and Retirement

Social Security

Disability and Unemployment Insurance

Public Assistance (Welfare, AFDC

payments, etc.)

Food Stamps

Child Support received for any

child(ren) not born of the parties

to this marriage

Dividends and Interest

Rents Received

All Other Sources (Specify)

TOTAL GROSS WEEKLY INCOME

HUSBAND

WIFE

B. ITEMIZED WEEKLY DEDUCTIONS from gross income:

State & Federal Income Taxes

Number of Exemptions Taken

Husband: Wife:

Social Security

Medical Insurance

(list all persons covered)

Coverage: Medical

Dental

Eye Care

Psych.

Union or Other Dues

Retirement or Pension Fund:

Mandatory: Optional:

Child Support Withheld from Pay

(not including this case)

Garnishments (itemized on a separate sheet)

Credit Union Debts

Savings: Thrift Plans ________

Credit Union _________

Savings __________

Bonds __________

Other (Specify) _________

Other (Specify): ________________

TOTAL WEEKLY DEDUCTIONS

C. WEEKLY DISPOSABLE INCOME

(A minus B: Subtract Total Weekly

Deductions from Total Weekly

Gross Income)

D. IN ALL CASES INVOLVING CHILD SUPPORT: Prepare and attach any Indiana Child Support Guideline Worksheet (with documentation verifying your income); or supplement with such a Worksheet within ten (10) days of the exchange of this Form.

E. SELECTED MONTHLY LIVING EXPENSES: Specify which party is to custodial parent and list names and relations of each number of the household whose expenses are included.

HUSBAND

WIFE

Rent or Mortgage Payments (residence)

Real Property Taxes (residence), if not included in mortgage payment

Insurance (residence), if not included in mortgage payment

Utilities (including water, sewer, electricity, gas, heat, and garbage)

Telephone

Child Support no withheld from pay (not including this case)

Medical (not covered in insurance)

Dental (not covered by insurance)

Insurance (life, health, accident, liability, disability; excluding payroll deducted and automobile)

School (Including, if applicable, colleges; universities; or trade schools)

Child Care and Preschool

Transportation (other than automobile)

Auto Payments

Automobile Insurance (not included in auto payment)

Other (specify)

MONTHLY TOTAL EXPENSES

AVERAGE WEEKLY EXPENSES (Divide Total Monthly Expenses by 4.3)

Note: Indicate which of the foregoing expenses are delinquent and the amount thereof.

F. DEBTS AND OBLIGATIONS: (Include credit union) attach additional sheets as needed.

CREDITOR'S NAME	DATE PAYABLE	BALANCE	MONTHLY PAYMENT





TOTAL

ATTACH A COPY OF THE MOST RECENT STATEMENTS FOR EACH DEBT.

Note: Indicate any special circumstances, i.e.: premarital debts, debts in arrears on the date of physical separation, or date of filing and the amount or number of payments in arrears.

PART II. NET WORTH

List all property owned, either individually or jointly. Indicate who holds or how title held: (H)usband; (W)ife; or (J)ointly. WHERE SPACE IS SUFFICIENT FOR COMPLETE INFORMATION OR LISTING, PLEASE ATTACH SEPARATE SCHEDULE.

	OWNERSHIP (H/W/J/)	VALUE	BALANCE(S) OWNED (Identify Creditors)
A. HOUSEHOLD FURNISHINGS (Value of Furniture, Appliances, and Equipment, as a whole; that is, you need not itemize)

B. AUTOMOBILES (Year and Make) Indicate Regular Driver	OWNERSHIP (H/W/J/)	VALUE	BALANCE(S) OWNED (Identify Creditors)




C. SECURITIES (Stocks, Bonds, Etc.)

COMPANY	OWNERSHIP (H/W/J/)	VALUE	NUMBER OF SHARES

D. CASH AND DEPOSIT ACCOUNTS (Including banks; savings and loan associations; unions; thrift plans; mutual funds; certificates of deposit; savings and checking accounts; IRAs; and Annuities)

INSTITUTION

OWNERSHIP

(H/W/J/)

VALUE

ACCOUNT NUMBER