Financial Declaration Page 4
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4
5
6
7
8
9
10
11Petitioner’s
Respondent’s
Deductions
Type of Deduction
Deductions
$
Federal Income Tax
$
$
State Income Tax
$
$
FICA
$
$
Health Insurance Premiums
$
$
Life Insurance Premiums
$
$
Union and other dues
$
$
Garnishment or Income Withholding Order
$
Retirement Deposits
(Including pensions, 401(k),
$
$
IRA, etc.)
$
Other
$
(Describe)
$
Other
$
(Describe)
$
Total
$
(6)
Net Income.
Petitioner
Respondent
$
Income
minus Deductions
$
(from (4))
(from (5))
(7)
Real Property.
(Attach evidence of items listed, such as mortgage statements, loan
documents, etc.)
Mortgage or Lien
In Whose
Current
Amount
Monthly
Holder
Property
Name?
Value
Owed
Payments
(Name & Address)
Home
(Address)
Petitioner
Respondent
Both
$
$
$
Other Real
Property
(Address)
Petitioner
Respondent
Both
$
$
$
Financial Declaration
Approved Board of District Court Judges September 10, 2008
Page 4 of 11
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