Financial Declaration Page 2
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11• the information in this Financial Declaration about myself is true and correct;
• the information about the other party is true and correct or is an estimate to the
best of my information and belief, and
• I have omitted nothing that is relevant to my financial status.
(2)
Social Security Number.
The last 4 digits of my Social Security Number are: _____________.
(3)
Employment Status.
(A)
I am employed by:
Name of Employer
Doing Business As (DBA)
Address
(B)
I am self employed by:
Name of Employer
Doing Business As (DBA)
Address
(C)
I am unemployed.
(4)
Monthly Income.
(If only one party receives income in a category, enter the amount in that
party’s column and enter $0 in the other party’s column. Attach evidence of items listed, such as most
recent pay stubs, tax returns, W-2 forms, or a work history report from the Department of Workforce
Services.)
Petitioner’s
Respondent’s
Income
Source of Income
Income
Work
(Including self employment, wages, salaries,
$
$
commissions, bonuses, and tips)
$
Rental Income
$
Financial Declaration
Approved Board of District Court Judges September 10, 2008
Page 2 of 11
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