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Sheet1 In the Hamilton Court Cause No. in re: the marriage of Petitioner and Respondent 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Union Dues (required for employment) 18 19 20 21 FINANCIAL DECLARATION LR 29-FL00-402.10 Form 402B State of Indiana County of Hamilton HUSBAND: WIFE: Name Name Address Address Employer Employer Attorney Attorney Address Address Telephone Telephone FINANCIAL DECLARATION OF: GROSS WEEKLY INCOME – attach last 3 paystubs Amount Salaries and Wages Pension/Retirement/Social Security/Disability/Unemployment/Worker's Comp. Child support received from prior marriage Dividends and interest Capital Gains expenses Business / self-employment income – not after expenses Commission / bonus / tips All other sources TOTAL GROSS WEEKLY INCOME (Lines 1-8) WEEKLY DEDUCTIONS Weekly court ordered child support for prior child(ren) Weekly legal duty child support for prior child(ren) Premiums pd for employee and child(ren) minus premiums pd for employee only Weekly alimony/support/maintenance paid to PRIOR spouse Self-employed tax (half of self-employment tax, annual amount ÷ 52 weeks Work related child care costs Extraordinary health care expenses – uninsured only Extraordinary educational expenses TOTAL GROSS WEEKLY DEDUCTIONS FROM GROSS INCOME TOTAL NET WEEKLY INCOME Page 1 Clear Form $ 0.00 $ 0.00 $ 0.00 $ 0.00 ---PAGE BREAK--- Sheet1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 H W J EXPENSES and DEDUCTIONS FROM INCOME Amount Federal income taxes State income taxes Local income taxes Social Security Taxes Retirement / pension fund (mandatory)(optional) Rent / mortgage payment (primary residence) Residence property taxes / insurance Maintenance on residence (lawn care,maid/cleaning, pool, HOA dues, etc) Food and supplies – eat at home / out with friends and children Electricity Personal clothing Personal expenses Gas, oil and wood heating Water, sewer, solid waste, trash collection Telephone (land line/cell service) includes internet and television service? Special work expenses (uniform, safety shoes, dues, parking) Laundry and dry cleaning Automobile – loan payment Automobile – gas, oil car wash Automobile – repairs/oil changes (estimate annual expense ÷ 12 months) Automobile – license plates, excise, and auto club Automobile – insurance Cable/satellite television/internet (if not included with telephone service above) Uninsured/Non-reimbursed Healthcare expenses (prescription/uninsured expenses only) Life insurance premiums/loan payments Health insurance premiums-not including H.S.A. contributions (total preimums paid less premiums shown on line 12 on page 1) Disability, accident and other insurance Entertainment (hobbies, travel, clubs, recreation) Charitable/church contributions Books, magazines, and newspapers Home tax preparation (non-reimbursable business expense) Children – clothing and shoes Children – allowance, membership in scouts, uniforms, fees Children – school lunches Children – book rental and tuition Children – sports, scouts, lessons, extracurricular activites, instrument rental, and tutors Birthday and holiday gifts for friends and family Membership at YMCA, health club, gym Installment Payments Current Balance TOTAL expenses and deductions from gross income Average weekly expenses and deductions from gross income Page 2 $ 0.00 $ 0.00 ---PAGE BREAK--- Sheet1 A. H W J 1 2 B. 3 4 5 6 7 C. 8 9 10 11 12 13 14 D. 15 16 17 18 E. 19 20 F. H W J 21 22 23 24 25 26 27 28 G. H W J 29 30 Household Furnishings/Furniture Electronic Equipment, Appliances Gross Value Debt Net In Husband's Possession In Wife's Possession Vehicles (boats, Rvs, (Make / Model / Year) Cash/Accounts/CDs (Name of bank account, last four digits of account number/account type) Securities / Stocks / Bonds Real Estate (including mobile homes) Fair Market Val. Mortgage Net Value Marital Residence (address) First mortgagor: Second mortgagor: Other residence (address) First mortgagor: Second mortgagor: Deferred compensation – profit sharing pension plans, Keoghs, IRSs, 401(k), SEP % Vested Vested FMV Business Interest % Interest % FMV Page 3 ---PAGE BREAK--- Sheet1 H. H W J 31 32 33 I. H W J 34 35 36 J H W J 37 38 39 40 41 42 43 Are other persons in your household working? If so, who? Occupation: Employer: Signature: Printed Name: Dated: Prepared by: Hamilton Cty Findec-Rev. 7-2014 Life Insurance (term and group) Face Amt. Policy No. Beneficiary Life Insurance (whole) Cash Value Loan Amt. % Interest Collections, jewelry, antiques, silver, china Value Debt Net Value List names, ages, and relationships of persons living in your household: I declare under the penalties of perjury that the foregoing, including any attachments(s), is true and correct to the best of my knowledge and belief. You are under a duty to supplement or amend this Financial Declaration prior to hearing if you learn the information provided is incorrect or the information provided is no longer true. Page 4