Financial Declaration Form (Page 2 of 5) in pdf

Financial Declaration Form Page 2

Estimate monthly expenses: (Specify which party is the custodial parent and list name and relationship of all members of household

whose expenses are included. _________________________________________________________________________________

MONTHLY EXPENSES

Husband/Father

Wife/Mother

Residential Rent Payment

Note or Mortgage Payment on Residence(s)

Food and Household Supplies

Utilities, Water, and Garbage Collection

Telephone and Cellular Phone

Medical, Dental and Disability Insurance Premiums (not

deducted from paycheck)

Life Insurance Premiums (not deducted from paycheck)

Child Support (from other relationship)

Work Related Day Care

Spousal Support (from prior marriage)

Auto Payment

Auto Insurance, taxes, gasoline, and maintenance

SUBTOTAL:

Real Property Tax on Residence(s)

Maintenance for household

Adult Clothing

Children’s Clothing

Cable Television, Satellite, and Internet/Online Services

Laundry and Dry Cleaning

Medical and Dental Expenses (not paid by insurance)

Prescriptions, Glasses, and Contacts (not paid by insurance)

Children’s incidental expenses

School lunches, supplies, field trips, and fees

Entertainment

Adult Incidental expenses

All Installment payments

Other (Specify):

SUBTOTAL:

TOTAL MONTHLY EXPENSES

Installment Loan Payments Section

Creditor

For

Monthly Payment

Balance

Owed by

SCCA 430 (12/2009)

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Financial Declaration Form Page 2