Fill and Sign the Financial Declaration Mississippi Form

IN THE CHANCERY COURT OF       COUNTY, MISSISSIPPI       COMPLAINANT VS. NO.             DEFENDANT FINANCIAL DECLARATION OF       (HUSBAND/WIFE) HUSBAND:       WIFE:       Address:       Address:                   Social Security No:       Social Security No:       Occupation:       Occupation:       Employer:       Employer:                   Birthdate:       Birthdate:       NAMES/AGES OF CHILDREN OF THE PARTIES:       NOTE: THIS DECLARATION MUST BE FILED WITH THE CHANCELLOR AND OPPOSITE PARTY BEFORE OR AT THE TIME OF THE HEARING. FAILURE BY EITHER PARTY TO COMPLETE, PRESENT, AND FILE THIS FORM AS REQUIRED WILL AUTHORIZE THE COURT TO ACCEPT THE STATEMENT OF THE OTHER PARTY AS THE BASIS FOR ITS DECISION. FILL OUR FOR SELF AND OTHER PARTY ALSO, INSOFAR AS POSSIBLE. ANY FALSE STATEMENT MADE HEREON MAY BE CONSIDERED A FRAUD UPON THE COURT. (FILL OUT YOUR OWN AND ESTIMATE FOR SPOUSE). STATEMENT OF INCOME, EXPENSES, ASSETS AND LIABILITIES Attach copies of State and Federal Income Tax Returns for last two taxable years and wage statements from your employer for last 8 weeks. HUSBAND WIFE 1. Gross Monthly income from: $       $       Salary and wages, including commissions, bonuses, allowances and overtime............................. $       $       (NOTE: To arrive at monthly income figures if paid weekly, multiply weekly income by 4.3; if paid bi- weekly income by 2.15) Pensions and retirement............................. $       $       Social Security..................................... $       $       Disability and unemployment insurance............... $       $       Public Assistance (welfare, AFDC payments, etc...... $       $       Child Support from any prior marriage............... $       $       Dividends and interest.............................. $       $       Rents............................................... $       $       All other sources (Specify):       .................. $       $             ............................................... $       $       TOTAL MONTHLY INCOME........................... $       $       2. Itemized monthly deductions from gross income:.....$       $       State and Federal Income Taxes.....................$       $       Number of exemptions taken.........................$       $       Social Security....................................$       $       Medical or other insurance (describe fully)........$       $             ..............................................$       $       Union or other dues................................$       $       Retirement or Pension fund.........................$       $       Savings Plan.......................................$       $       Credit Union.......................................$       $       Other (Specify)       ..............................$       $             ..............................................$       $       TOTAL MONTHLY DEDUCTIONS........................$       $       3. Net monthly take home pay..........................$       $       4. Debts and obligations (individually and jointly): Creditors Name: Owed for What: Date Payable: Balance Due: Monthly Payment:                                                                                                                                                       TOTAL...................................................$       $       (If insufficient space, insert total and attach schedule) 5. All property of the parties known to me owned individually or jointly indicate who holds or how title held (H) Husband, (W) Wife, or (J) Jointly. WHERE SPACE IS INSUFFICIENT FOR COMPLETE INFORMATION OR LISTING, PLEASE ATTACH SEPARATE SCHEDULE. 6. VALUE OWED THEREON (a) Household furnishings, furniture, appliances and equipment..$       $       (b) Automobile (year/make) ..............$       $       ..............$       $       (c) Securities--stocks and bonds ..............$       $       ..............$       $       ..............$       $       (d) Cash and Deposit Accounts (banks, savings, loans, credit unions and checkings)       .................................$       $             .......................................................$       $       (e) Life Insurance: Name of Company Policy No. Face Amount Cash value Accumulated Div. or Loan Amount                                                                                                             (f) Profit Sharing/Retirement Acct. Value of Interest and Amt. Presently Vested Name             Name             (g) Other Personal Property and Assets (specify)       (h) Real Estate (where more than one parcel of real estate owned, attach sheet with identical information for all additional property) Address       Type of Property       Date of Acquisition       Original Cost $       Total Present Value $       Cost of Additions $       Basis of Valuation       Total Cost $       Mtg. Balance $       Other Liens $       Equity $       Monthly Amortization $       And to Whom       Taxes $       Individual Contributions $             (i) Business Interest (indicate name, share, type of business, value less indebtedness)       (j) Other Assets (Specify)       6. Total monthly expenses: (Specify which party is the custodial parent and list name and relationship of all members of the household whose expenses are included)                   (FILL OUT FOR SELF AND ALSO ESTIMATE OR SPOUSE): HUSBAND WIFE 7. Rent or mortgage payments (residence)................. $       $       Real property taxes (residence)........................ $       $       Real property insurance (residence)................. $       $       Maintenance (residence)................................ $       $       Food and household supplies............................ $       $       Utilities including water, electricity, gas and heat... $       $       Telephone.............................................. $       $       Laundry & Cleaning..................................... $       $       Clothing............................................... $       $       Medical................................................ $       $       Dental................................................. $       $       Insurance (life, health liability, disability-exclude payroll deduction)..................................... $       $       Child Care............................................. $       $       Payment of child/spousal support re: prior marriage.... $       $       School................................................. $       $       Entertainment (includes clubs, social obligations, travel, recreation).................................... $       $       Incidentals (grooming, tobacco, alcohol. gifts, and donations)............................................. $       $       Transportation (other than automobile)................. $       $       Auto expense (gas, oil, repair, insurance)............. $       $       Auto payments.......................................... $       $       Installment payments (insert total).................... $       $       Other Expenses (insert total and specify on attached schedule).............................................. $       $       TOTAL EXPENSES............................................. $       $       I declare to the Court that the foregoing, including any attachments, is true and correct and that this declaration was executed on the       day of       , 20       at       County, Mississippi. SIGNATURE OF HUSBAND/WIFE       After discussion with me, these figures are my client's figures. FIRM NAME:       ATTORNEY'S ADDRESS             ATTORNEY'S SIGNATURE TELEPHONE #       BRING TO THE HEARING ALL DOCUMENTS AND OTHER SUPPORTING INFORMATION NECESSARY TO VERIFY OR EXPLAIN THE STATEMENTS MADE IN THIS DECLARATION, INCLUDING BUT NOT LIMITED TO PASSBOOKS, CHECKBOOKS, CANCELLED CHECKS, CERTIFICATES, POLICIES AND OTHER DOCUMENTATION. ALSO, PREPARE A LIST OF ALL PERSONAL AND REAL PROPERTY AND GIVE ORIGINAL COST AND PRESENT VALUE FOR BOTH PARTIES.