Short Form Financial Declaration Page 2
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MONTHLY INCOME
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If you are presently unemployed, answer questions 1 – 2 and then go on to the rest of the
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questions. If you are employed, print “not applicable” in questions 1 – 2 and go on to the rest
of the questions.
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1.
__________ I am presently unemployed and have been unemployed since
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_______________________________________
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(date of your last employment)
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2.
My last employer was ________________________________________________ and I
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earned $__________________ per hour / week / month (circle one)
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Answer all of the following questions.
If the question is not applicable in your particular
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circumstances, print “N/A in the spaces.
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Monthly Money Earned and Received
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3.
I am employed and earn the following wages:
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I am paid by the hour and my hourly wage is:
$ __________________
I work __________ hours per week.
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I am paid (circle one) every week; every 2 weeks; 1x a month
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2x a month and without anything being deducted from it, each
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check is for (attach last 3 paystubs):
$ _________________
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I work overtime approximately __________ hours per
month at the rate of $ _____________ per hour for an
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average monthly overtime earning of:
$ _________________
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I receive commissions each month in the amount of:
$ ________________
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(averaged over a year)
I receive tips each month in the amount of:
$ ________________
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(averaged over a year)
I receive bonuses each month in the amount of:
$ ________________
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(averaged over a year)
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Income Other Than Wage Earnings
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4.
I receive child support each month from the other party in the
amount of (amount of court order $_____________):
$ ________________
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