Fill and Sign the Defendantrespondent Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 Code: Name: ______________________________ Address: ____________________________ ____________________________________ Telephone:___________________________ IN THE _______________ JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF __________________ __________________________________, ) Plaintiff/Petitioner ) Case No. ____________________ ) vs ) Dept. No. ___________________ ) __________________________________, ) Defendant/Respondent) ____________________________________) SHORT FORM FINANCIAL DECLARATION STATE OF NEVADA ) ) County of ________________) I, __________________________________, being duly sworn and under the penalties of (print your name) perjury, depose and state as follows: I have read the contents of this Financial D eclaration and am competent to testify as to the contents, and the contents are true of my own knowledge except for those matters stated on information and belief, and as to those matters, I believe them to be true. SUBSCRIBED and SWORN to before me _____________________________________ ( sig natu re ) this _______day of _____________________, 20____. ____________________________________________ NOTARY PUBLIC 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2 1. __________ I am presently unemployed and have been unemployed since _______________________________________ (date of your last employment) 2. My last employer was ________________________________________________ and I earned $__________________ per hour / week / month (circle one) Monthly Money Earned and Received 3. I am employed and earn the following wages: I am paid by the hour and my hourly wage is: $ __________________ I work __________ hours per week. I am paid (circle one) every week; every 2 weeks; 1x a month 2x a month and without anything being deducted from it, each check is for (attach last 3 paystubs ): $ _________________ I work overtime approximately __________ hours per month at the rate of $ _____________ per hour for an average monthly overtime ear ning of: $ _________________ I receive commissions each month in the amount of: $ ________________ (averaged over a year) I receive tips each month in the amount of: $ ________________ (averaged over a year) I receive bonuses each month in the amount of: $ ________________ (averaged over a year) Income Other Than Wage Earnings 4. I receive child support each month from the other party in the amount of (amount of court order $_____________): $ ________________ If you are presently unemployed, answer questions 1 – 2 and then go on to the rest of the questions. If you are employed, print “not applic able” in questions 1 – 2 and go on to the res t of the questions. Answer all of the following questions. If th e question is not applicable in your particula r circumstances, print “N/A in the spaces. MONTHLY INCOME 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3 5. I receive child support each month from someone else in the amount of (amount of court order $_____________) : $_________________ 6. I receive alimony/spousal support each month from the other party in the amount of (amount of court order $_____________) : $ ________________ 7. I receive alimony/spousal support each month from someone else in the amount of (amount of court order $_____________) : $_________________ 8. I receive the following government assistance: I receive Social Security Benefits each month in the amount of: $ ________________ I receive Non Social Security Disability each month in the amount of: $ _________________ I receive State or County assistance (welfare, TANF, SIIS, etc.) each month in the amount of: $ ________________ I receive unemployment each month in the amount of: $ ________________ 9. I receive retirement benefits each month in the amount of: $ ________________ 10. I receive investment income each month in the amount of: $ ________________ 11. I receive income from rental properties (excluding depreciation ) each month in the amount of: $ _________________ 12. I live with someone (friend, relative, significant other) who contributes to the living expenses each month in the amount of: $ _________________ 13. I am receiving educational or school benefits in the amount of: $ _________________ 14. I am receiving money from friends, relatives, others each month in the amount of: $ __________________ 15. I am receiving other sources of income, including but not limited to monthly distributions from a trust or will in the amount of: $ ________ __________ MY TOTAL MONTHLY INCOME FROM ALL SOURCES IS: $ ________ __________ (this amount is your “gross income”) HOW MUCH IS BEING WITHHELD FROM YOUR INCOME EACH MONTH? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4 Federal income taxes: $ _______________ Social Security $ _______________ Medicare taxes $ _______________ Child support for children with the other party $ _______________ Child support for children with someone else $________________ Alimony/spousal support paid to the other party $_________________ Alimony/spousal support paid to someone else: $_________________ Retirement, 401K, etc. $ _________________ Health insurance total: $_________________ Of this amount, $__________ is the amount paid for your and the other party’s children. Any other garnishments or withholdings, please list: _________________________________ $ _______________ _________________________________ $ _______________ _________________________________ $ _______________ TOTAL WITHHOLDING FROM PAYCHECK: $ _______________ YOUR TOTAL EXPENSES EACH MONTH (REPORT ONLY THE AMOUNT YOU ACTUALLY PAY) 1. Each month I pay rent or mortgage or I contribute to the rent or mortgage where I live in the amount of: $ _________________ 2. For food each month, I spend or contribute to the family with whom I am living the amount of: $ _________________ 3. For house/apartment utilities (gas, power, water, garbage, sewer) I pay or contribute to my household the amount of: $ _________________ 4. Life insurance $_____ ____________ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 5 Vehicle payment each month in the amount of: $ _________________ Fuel for the vehicle in the amount of: $ ________________ Insurance for the vehicle (if paid over a period of six months or a year, average the payment out) $ ________________ Repairs and maintenance (averaged over a year) $ ________________ 6. I do not own a vehicle but my monthly transportation costs (bus, taxi, etc.) are: $ _________________ 7. I have medical bills that I pay on each month in the amount of: $ ________________ 8. I have medical prescriptions each month in the amount of: $ _________________ 9. I pay health insurance (not deducted from my check) in the amount of: $ _________________ 10. I am paying child support each month that is not deducted directly from my paycheck in the amount of (amount of court order $_____________) : $ _________________ 11. I am also legally responsible for the support of others, namely: _________________________________________________ each month in the amount of (amount of court order $_____________) : $_________________ 12. Each month I pay child car e in the amount of: $ _________________ 13. I have credit card /charge account payments each month and pay those charges as follows : Name of Credit Card or Charge Account ________________________________________in the amount of: $ ________________ ________________________________________in the amount of : $ _________________ ________________________________________in the amount of $ _________________ ________________________________________in the amount of $ __________________ ________________________________________in the amount of $ __________________ ________________________________________in the amount of $ __________________ 14. Clothing, cleaning, laundry, etc. each month: $ _________________ 15. I have school or educational expenses each month of: $ _________________ 5. I have a vehicle and pay the following each month: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 6 16. My recreational expenses each month are: $ _________________ 17. My charitable expenses each month are: $_________________ 18. Other expenses not listed above, please list: _____________________________________________ $ _____ ____________ _____________________________________________ $ _____ ____________ _____________________________________________ $ _____ ____________ TOTAL MONTHLY EXPENSES: $ _________________ NET INCOME (DEFICIT) EACH MONTH (TOTAL MONTHLY INCOME MINUS TOTAL WITHHOLDING MINUS TOTAL MONTHLY EXPENSES) : $_____ ____________ ASSETS AND DEBTS 1. House/Mobile Home (circle one) Separate/Community/Joint (circle one) Who has possession? (circle one) me/the other party a . H o w m u c h i t i s w o r t h : $ ___________________ b. How much you owe on it: $ _________________ 2. Checking Accounts: Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession _____________________________________________ $ ________ __________ _________________________________________________________ $ __________________ _________________________________________________________ $ __________________ 3. Savings Accounts: Write the Account’s Location, Separate/Community/Joint Property, and Who has Possession: _________________________________________________________ $ ________ __________ In the following section, list ALL assets and debts you have, either separately or jointly with the other party. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 7 _________________________________________________________ $ __________________ _________________________________________________________ $ _________________ 4. Cash you have on hand: $ __________________ 5. Retirement Accounts (indicate in whose name accounts are held) _________________________________________________________ $ __________________ _________________________________________________________ $ _________________ _________________________________________________________ $ ___________________ _________________________________________________________ $ __________________ 6. Vehicles: (list ALL vehicles owned by you and/or the other party, even if your name is not on the registration and include such things as motorcycles, boats and recreational vehicles) a. Make and model:_________________________________ What you owe on the vehicle: $ ___________________ What the vehicle is worth: $ _________________ b. Make and model: _________________________________ What you owe on the vehicle: $ ___________________ W h a t t h e v e h i c l e i s w o r t h : $ ___________________ c. Make and model: _________________________________ What you owe on the vehicle: $ _________________ What the vehicle is worth: $ _________________ 7. Stocks and bonds: $_____ ____________ 8. Credit Cards and Store Charge Accounts: Name of Account Balance Minimum Monthly Payment ______________________________ $_________________ $ __________________ _______________________________ $ _________________ $ __________________ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8 _______________________________ $ _________________ $ ___________________ _______________________________ $ _________________ $ __________________ _______________________________ $ _________________ $ __________________ Asset Value of Asset ___________________________________________ $ _________________ ___________________________________________ $ __________________ ___________________________________________ $ _________________ Debt Balance Owed on Debt ___________________________________________ $ __________________ ___________________________________________ $ _________________ ___________________________________________ $ _________________ ___________________________________________ $ ___________________ ___________________________________________ $ __________________ ___________________________________________ $ _________________ ___________________________________________ $ ___________________ ___________________________________________ $ __________________ On the lines below, please list any other assets or debts you have that have not been previously listed. Assets such as furniture, jewelry, boats, assets held in your child’s name or joint tenancy with any othe r person, and personal loans owed to you. Debts such as medical bills and personal loans owed to others.