Financial Declaration Form Page 4
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67.
Monthly Expenses After Separation
Tell the court what your monthly expenses are (or will be) after separation. If you have
dependent children, your expenses must be based on the parenting plan or schedule you
expect to have for the children.
A. Housing Expenses
F. Transportation Expenses
Rent / Mortgage Payment
Automobile payment (loan or lease)
Property Tax (if not in monthly payment)
Auto insurance, license, registration
Homeowner’s or Rental Insurance
Gas and auto maintenance
Other mortgage, contract, or debt
Parking, tolls, public transportation
payments based on equity in your home
Homeowner’s Association dues or fees
Other transportation expenses
Total Housing Expenses
Total Transportation Expenses
B. Utilities Expenses
G. Personal Expenses
(not children’s)
Electricity and heating (gas and oil)
Clothes
Water, sewer, garbage
Hair care, personal care
Telephone(s)
Recreation, clubs, gifts
Cable, Internet
Education, books, magazines
Other (specify):
Other Personal Expenses
Total Utilities Expenses
Total Personal Expenses
C. Food and Household Expenses
H. Other Expenses
Groceries for (number of people): _____
Life insurance (not deducted from pay)
Household supplies
Other (specify):
(cleaning, paper, pets)
Eating out
Other (specify):
Other (specify):
Other (specify):
Total Food and Household Expenses
Total Other Expenses
D. Children’s Expenses
List all Total Expenses from above:
Childcare, babysitting
A. Total Housing Expenses
Clothes, diapers
B. Total Utilities Expenses
Tuition, after-school programs, lessons
C. Total Food and Household Expenses
Other expenses for children
D. Total Children’s Expenses
Total Children’s Expenses
E. Total Health Care Expenses
F. Total Transportation Expenses
E. Health Care Expenses
G. Total Personal Expenses
Insurance premium (health, vision, dental)
H. Total Other Expenses
Health, vision, dental, orthodontia, mental
I. All Total Expenses (add A - H above)
health expenses not covered by insurance
Other health expenses not covered by
Use section 10 below to explain any unusual
insurance
expenses, or attach additional pages.
Total Health Care Expenses
RCW 26.18.220(1)
Financial Declaration
Mandatory Form (09/2016)
FL All Family 131
p. 4 of 6
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