Financial Declaration Form

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STATE OF SOUTH CAROLINA
)
IN THE FAMILY COURT OF THE
)
_____ JUDICIAL CIRCUIT
COUNTY OF ______________________________ )
)
)
FINANCIAL DECLARATION
Plaintiff,
)
OF ______________________________
vs.
)
)
Defendant. )
Docket No. ___________________________________
HUSBAND/FATHER
WIFE/MOTHER
Address
Address
Age
Age
Occupation
Occupation
Employer
Employer
Employer
Employer
Address
Address
Gross Monthly Income
Husband/Father
Wife/Mother
1
Principal Earnings from Employment
2
Overtime, Tips, Commission, Bonuses
Pensions, Retirement, and Annuities income
Additional Employment income
Social Security Benefits (SSA) and VA Benefits
Disability and Worker’s Compensation Benefits
Unemployment and AFDC
Spousal or Child Support (from other marriage/relationship)
Dividends, Interest, Trust Income, and Capital Gains
Rental Income and Business Profits
Other (Specify):
TOTAL GROSS MONTHLY INCOME
Payroll Deductions from Monthly Income
Husband/Father
Wife/Mother
3
Federal Income Tax
State Income Tax
Social Security and Medicare Tax (FICA)
Self-Employment Tax
Health and Dental Insurance (Adult)
Health and Dental Insurance (Child)
Union Dues
Voluntary Retirement Contribution (401(k), 457, IRA)
Mandatory Retirement Contribution
Savings Plan
Other (Specify):
TOTAL MONTHLY DEDUCTIONS
4
NET MONTHLY INCOME
SCCA 430 (12/2009)
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