Form Ujs-304b Financial Affidavit Page 2
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4STATE OF SOUTH DAKOTA )
IN CIRCUIT COURT
:SS
COUNTY OF______________ )
___________ JUDICIAL CIRCUIT
_______________________,
DIV _____
Plaintiff,
FINANCIAL AFFIDAVIT
vs.
_______________________,
Defendant.
I, ________________________________, hereby swear under oath and under penalty of law that the following is true.
(Name of party filling out this affidavit)
(1)
My mailing address is ______________________________________________________
(2)
My telephone number is (
) _______________________________________
(3)
I am (check one) _____ EMPLOYED _____ UNEMPLOYED _____ SELF-EMPLOYED
(4)
(If employed) my monthly gross pay is:
$_____________________________.
(5)
Monthly gain or profit from a business or profession (self-employment): $________________________.
(6)
Pension, retirement, disability, veterans, social security or insurance payments received regularly:
$___________________ per ______________.
(7)
Interest, dividends, rentals, royalties or other gains: $______________________ per _________________.
(8)
Gain from sale, trade or conversion of capital assets: $________________________.
(9)
Unemployment insurance and workers compensation benefits: $___________________ per _______________.
(10)
Benefit in lieu of compensation including but not limited to military pay allowances: ______________________ per
_______________________________.
(11)
Other income (including spousal support received). Explain:__________________________________________.
$___________________ per ______________.
TOTAL GROSS MONTHLY INCOME (Add 4-11):
$_______________________
(12)
Income tax based on one withholding allowance for a single taxpayer (not actual number of dependents):
$_______________.
(13)
Social Security and Medicare taxes withheld from wages or salary: $___________________.
(15)
Contributions to an IRS qualified retirement plan not exceeding 10% of gross income:$ __________________.
(16)
Unreimbursed employee business expenses (Attach IRS form 2106): $________________________________.
(17)
Payments made on other support orders OTHER THAN FOR CHILDREN IN THIS PROCEEDING: $___________.
(Attach court order and evidence of payments).
(18)
Payments made for spousal support: $_____________________.
TOTAL DEDUCTIONS (Add 12-18): $___________________
NET MONTHLY INCOME (SUBTRACT TOTAL DEDUCTIONS FROM GROSS MONTHLY
INCOME): $__________________
(19)
My total gross income before deductions for the previous year was $______________________.
(20)
My total gross income before deductions for two years ago was $______________________.
(21)
Including myself, I have the following number of dependents: _____________________.
(22)
Do you have health insurance available for dependents through your employer? _________________
Page 2 of 4
Form UJS-304B
Rev. 01/2015
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