Short Form Financial Declaration Page 4
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Federal income taxes:
$ _______________
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Social Security
$ _______________
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Medicare taxes
$ _______________
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Child support for children with the other party
$ _______________
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Child support for children with someone else
$________________
Alimony/spousal support paid to the other party
$_________________
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Alimony/spousal support paid to someone else:
$_________________
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Retirement, 401K, etc.
$ _________________
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Health insurance total:
$_________________
Of this amount, $__________ is the
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amount paid for your and the other party’s
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children.
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Any other garnishments or withholdings, please list:
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_________________________________
$ _______________
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_________________________________
$ _______________
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_________________________________
$ _______________
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TOTAL WITHHOLDING FROM PAYCHECK:
$ _______________
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YOUR TOTAL EXPENSES EACH MONTH (REPORT ONLY THE AMOUNT YOU
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ACTUALLY PAY)
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1.
Each month I pay rent or mortgage or I contribute to the
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rent or mortgage where I live in the amount of:
$ _________________
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2.
For food each month, I spend or contribute to the family with
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whom I am living the amount of:
$ _________________
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3.
For house/apartment utilities (gas, power, water, garbage, sewer)
I pay or contribute to my household the amount of:
$ _________________
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4.
Life insurance
$_________________
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Parent category: Financial