Financial Declaration Page 3
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11Petitioner’s
Respondent’s
Income
Source of Income
Income
$
Business Income
$
$
Interest and Dividends
$
Retirement Income
(Including pensions, 401(k), IRA,
$
$
etc.)
$
Worker’s Compensation
$
$
Social Security Disability
$
(SSDI and SSI)
$
Private Disability Insurance
$
$
Social Security
$
(Do not include SSDI or SSI)
$
Unemployment Benefits
$
$
Education Benefits
$
$
Veteran’s Benefits
$
$
Alimony
$
$
Child Support
$
$
Payments from Civil Litigation
$
$
Victim Restitution
$
$
Public Assistance
$
(Including AFDC, welfare, etc.)
$
Support from household members
$
$
Support from non-household members
$
$
Other
$
(Describe)
$
Other
$
(Describe)
$
Total
$
I have no income because:
(5)
Monthly Deductions.
(If only one party has a deduction in a category, enter the amount in
that party’s column and enter $0 in the other party’s column. Attach evidence of claims, such as most
recent pay stubs, tax returns, W-2 forms, or a work history report from the Department of Workforce
Services.)
Financial Declaration
Approved Board of District Court Judges September 10, 2008
Page 3 of 11
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