Fill and Sign the Declaration Statement Form

FINANCIAL DECLARATION STATEMENT PARISH OF ____________DOCKET NO.__________ _______ JUDICIAL DISTRICT COURT PLAINTIFF_______________________ ATTORNEY:_________________________ DEFENDANT_____________________ ATTORNEY:_________________________ This declaration is submitted on behalf of ____________________Hearing Date______________ What kind of hearing is this? _______________________________________________________ When were the parties married?_______________When did they physically separate? _________ What is the date of the legal separation, if any?____________Divorce? _____________________ Names and ages of children: Give a list of prior court action, if any: _______________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Gross Monthly Income (If paid weekly, multiply by 4.3: If bimonthly by 2.15) From Wages $_______________ Public Assistance or Child Support $_______________ Any Other Income, Specify: $_______________ Specify Source____________________________ Deductions from Wages: Federal Income Taxes $_______________ State Income Taxes $_______________ Social Security $_______________ Medical Insurance $_______________ Credit Union or Pension Fund $_______________ Other $_______________ Net Monthly Income, Take-Home Pay: $_________________ Employees must bring check stubs to Court Assets: House (Value) $_______________ Lot (Value) $_______________ Car (Value) $_______________ Savings or Checking Accounts $_______________ $_______________ Other $_______________ Total Monthly Expenses Rent $_______________ Residential Taxes & Licenses $_______________ Food & Household Supplies $_______________ Water, Electricity, Gas $_______________ Telephone $_______________ Clothing $_______________ Medical & Dental $_______________ Insurance $_______________ Child Care $_______________ School Expenses $_______________ Entertainment & Expenses $_______________ Gasoline, Oil, Auto Repairs $_______________ Installment Payments Auto $_______________ Banks $_______________ Finance Companies $_______________ (Name)________________ $_______________ Credit Cards (Name)________________ $_______________ (Name)________________ $_______________ (Name)________________ $_______________ Total Monthly Expenses $_________________ On this _____ day of _________________ 20___, came and appeared the Affiant, who, on being sworn under penalty of perjury, declared that the above captioned declaration is true and correct. ______________________________ Affiant _____________________________ Notary Public USE OTHER SIDE IF NEEDED FOR ADDITIONAL INFORMATION