Sworn Financial Statement
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District Court
Denver Juvenile Court
___________________ County, Colorado
Court Address:
In re:
The Marriage of:
Parental Responsibilities concerning:
______________________________________________________
Petitioner:
and
Co-Petitioner/Respondent:
COURT USE ONLY
Attorney or Party Without Attorney
:
Case Number:
(Name and Address)
Phone Number:__________ E-mail:___________________________
Division ______ Courtroom _______
FAX Number:___________ Atty. Reg. #: __________________
SWORN FINANCIAL STATEMENT
I, ___________________________________________________ (full name)
am
am not currently employed.
I am employed ____ hours per week. I am paid
weekly
bi-weekly
twice a month
monthly.
My pay is based on a
Monthly Salary
Hourly rate of $__________
Other: _________________________
Date employment began _______________________________.
My occupation is: ____________________________ Name of employer: _______________________________
Address of employer: _________________________________________________________________________
If unemployed, what date did you last work? _______________________
I am unemployed due to
disability
involuntary layoff at work
other: ________________________________
This household consists of _____ adult(s), and ______ minor child(ren).
I believe the monthly gross income of the other party is $___________.
Annual gross income (last tax year 20__) for Petitioner $ _________,
Co-Petitioner/Respondent $ __________
1.
Monthly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.)
Gross Monthly Income
$
Social Security Benefits (SSA)
$
(before taxes and
deductions) from salary and wages, including
SSDI
(Disability insurance – entitlement
commissions, bonuses, overtime, self-
program)
employment, business income, other jobs,
SSI
(supplemental income – need based)
and monthly reimbursed expenses.
Unemployment & Veterans’ Benefits
Disability, Workers’ Compensation
Pension & Retirement Benefits
Interest & Dividends
Public Assistance (TANF)
Other - ___________________
Total Monthly Income
$
Miscellaneous Income
Royalties, Trusts, and Other Investments
$
Contributions from Others
$
Dependent Children’s monthly gross
All other sources, i.e. personal injury
income. Source of Income: __________
settlement, non-reported income, etc.
Rental Net Income
Expense Accounts
Child Support from Others
Other - ___________________
Spousal Support from Others
Other - ___________________
Total Monthly Miscellaneous Income
$
$
Total Income
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2
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