Fill and Sign the Financial Declaration Form

Superior Court of Washington, County of In re: Petitioner/s (person/s who started this case) : And Respondent/s (other party/parties) : No. Financial Declaration of (name): ( FNDCLR ) Financial Declaration 1. Your personal information Name: Highest year of education you completed: Your job/profession is: Are you working now? Yes. List the date you were hired (month / year): No. List the last date you worked (month / year) : What was your monthly pay before taxes: $ Why are you not working now? 2. Summary of your financial information (Complete this section after filling outl le e tl ou槰 leit 槰oue..槰 1. Total Monthly Net Income (copy from section 3 , line C. 3. ) $ 2. Total Monthly Expenses After Separation (copy from section 7 , line I. ) $ 3. Total Monthly Payments for Other Debts (copy from section 9 ) $ 4. Total Monthly Expenses + Payments for Other Debts (add line 2 and line 3) $ RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 1 of 6 Gross Monthly Income of Other Party (copy from section 3. A. ) $ 3. Income List monthly income and deductions below for you and the other person in your case. If your case involves child support, this same information is required on your Child Support Worksheets . If you do not know the other person’s financial information, give an estimate. Tip: If you do not get paid once a month, calculate your monthly income like this: Monthly income = Weekly x 4.3 or 2-week x 2.15 or Twice a month x 2 A. Gross Monthly Income (before taxes, deductions, or retirement contributions) You Other Party Monthly wage / salary Income from interest / dividends Income from business Spousal support / maintenance received (Paid by: ) Other income Total Gross Monthly Income (add all lines above) Total gross income for this year before deductions (starting January 1 of this year until now) B. Monthly Deductions You Other Party Income taxes (federal and state) FICA (Soc.Sec. + Medicare) or self-employment taxes State Industrial Insurance (Workers’ Comp.) Mandatory union or professional dues Mandatory pension plan payments Voluntary retirement contributions (up to the limit in RCW 26.19.071(5)(g)) Spousal support / maintenance paid Normal business expenses Total Monthly Deductions (add all lines above) C. Net Monthly Income You Other Party 1. Total Gross Monthly Income (from A above) RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 2 of 6 2. Total Monthly Deductions (from B above) 3. Net Monthly Income (Line 1 minus Line 2) 4. Other Income and Household Income Tip: If this income is not once a month, calculate the monthly amount like this: Monthly income = Weekly x 4.3 or 2-week x 2.15 or Twice a month x 2 A. Other Income (Do not repeat income you already listed on page 2.) You Other Party Child support received from other relationships Other income (From: ) Other income (From: ) Total Other Income (add all lines above) B. Household Income (Monthly income of other adults living in the home) Your Home Other Party’s Home Other adult’s gross income (Name: ) Other adult’s gross income (Name: ) Total Household Income of other adults in the home (add all lines above) 5. Disputed Income – If you disagree with the other party’s statements about anyone’s income, explain why the other party’s statements are not correct, and your statements are correct: 6. Available Assets List your liquid assets, like cash, stocks, bonds, that can be easily cashed. Cash on hand and money in all checking & savings accounts $ RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 3 of 6 Stocks, bonds, CDs and other liquid financial accounts $ Cash value of life insurance $ Other liquid assets $ Total Available Assets (add all lines above) 7. Monthly Expenses After Separation Tell the court what your monthly expenses are (or will be) after separation. If you have dependent children, your expenses must be based on the parenting plan or schedule you expect to have for the children . A. Housing Expenses F. Transportation Expenses Rent / Mortgage Payment Automobile payment (loan or lease) Property Tax (if not in monthly payment) Auto insurance, license, registration Homeowner’s or Rental Insurance Gas and auto maintenance Other mortgage, contract, or debt payments based on equity in your home Parking, tolls, public transportation Homeowner’s Association dues or fees Other transportation expenses Total Housing Expenses Total Transportation Expenses B. Utilities Expenses G. Personal Expenses (not children’s) Electricity and heating (gas and oil) Clothes Water, sewer, garbage Hair care, personal care Telephone(s) Recreation, clubs, gifts Cable, Internet Education, books, magazines Other (specify): Other Personal Expenses Total Utilities Expenses Total Personal Expenses C. Food and Household Expenses H. Other Expenses Groceries for (number of people): _____ Life insurance (not deducted from pay) Household supplies (cleaning, paper, pets) Other (specify): Eating out Other (specify): Other (specify): Other (specify): Total Food and Household Expenses Total Other Expenses D. Children’s Expenses List all Total Expenses from above: Childcare, babysitting A. Total Housing Expenses Clothes, diapers B. Total Utilities Expenses Tuition, after-school programs, lessons C. Total Food and Household Expenses Other expenses for children D. Total Children’s Expenses Total Children’s Expenses E. Total Health Care Expenses F. Total Transportation Expenses E. Health Care Expenses G. Total Personal Expenses RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 4 of 6 Insurance premium (health, vision, dental) H. Total Other Expenses Health, vision, dental, orthodontia, mental health expenses not covered by insurance I. All Total Expenses (add A - H above) Other health expenses not covered by insurance Use section 10 below to explain any unusual expenses, or attach additional pages. Total Health Care Expenses 8. Debts included in Monthly Expenses listed in section 7 above Debt for what expense (mortgage, car loan, etc.) Who do you owe (Name of creditor) Amount you owe this creditor now Last Monthly Payment made $ Date: $ Date: $ Date: $ Date: 9. Monthly payments for other debts ( not included in expenses listed in section 7) Describe Debt (credit card, loan, etc.) Who do you owe (Name of creditor) Amount you owe this creditor now Last Monthly Payment (Date and Amount) $ Date: $ $ Date: $ $ Date: $ $ Date: $ $ Date: $ $ Date: $ Total Monthly Payments for Debts 10. Explanation of expenses or debts (if any needed): 11. Lawyer Fees List your total lawyer fees and costs for this case as of today. Amount paid $ Source of the money you used to pay these fees and costs: Amount still owed $ Describe your agreement with your lawyer to pay your fees and costs: Total Fees/Costs $ RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 5 of 6 I declare under penalty of perjury under the laws of the state of Washington that the facts I have provided on this form are true. Signed at (city and state): Date: Sign here Print name Financial Records – Y o t .ttl peouvid financial e couedt at e qtie d by tlaltl and tlal and loucal coutel etl t. Te t e couedt .ay incltd :  Personal Income Tax Returns  Pay stubs  Partnership or Corporate Income Tax Returns  Other financial records Important! Do not attach financial records to this form. Financial records should be served on the other party and filed with the court separately using the Sealed Financial Source Documents cover sheet (FL All Family 011). If filed separately using the cover sheet, the records will be sealed to protect your privacy (although they will be available to all parties and lawyers in this case, court personnel and certain state agencies and boards.) See GR 22(c)(2). RCW 26.18.220(1) Mandatory Form (09/2016) FL All Family 131 Financial Declaration p. 6 of 6