Fill and Sign the Sworn Financial Statement Colorado Form

 District Court  Denver Juvenile Court ___________________ County, Colorado Court Address: In re:  The Marriage of:  The Civil Union of:  Parental Responsibilities concerning: ______________________________________________________ Petitioner: and Co-Petitioner/Respondent: COURT USE ONLY Attorney or Party Without Attorney (Name and Address) : Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom SWORN FINANCIAL STATEMENT I, ___________________________________________________ (full name)  am  am not currently employed. I am employed ____ hours per week. I am paid  weekly  bi-weekly  twice a month  monthly. My pay is based on a  Monthly Salary  Hourly rate of $__________  Other: _________________________ Date employment began _______________________________. My occupation is: ____________________________ Name of employer: _______________________________ Address of employer: _________________________________________________________________________ If unemployed, what date did you last work? _______________________ I am unemployed due to  disability  involuntary layoff at work  other: ________________________________ This household consists of _____ adult(s), and ______ minor child(ren). I believe the monthly gross income of the other party is $___________. Annual gross income (last tax year 20__) for Petitioner $ _________,  Co-Petitioner/Respondent $ __________ 1. Monthly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.) Gross Monthly Income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, self- employment, business income, other jobs, and monthly reimbursed expenses. $ Social Security Benefits (SSA)  SSDI (Disability insurance – entitlement program)  SSI (supplemental income – need based) $ Unemployment & Veterans’ Benefits Disability, Workers’ Compensation Pension & Retirement Benefits Interest & Dividends Public Assistance (TANF) Other - ___________________ Total Monthly Income $ Miscellaneous Income Royalties, Trusts, and Other Investments $ Contributions from Others $ Dependent Children’s monthly gross income. Source of Income: __________ All other sources, i.e. personal injury settlement, non-reported income, etc. Rental Net Income Expense Accounts Child Support from Others Other - ___________________ Spousal/Partner Support from Others Other - ___________________ Total Monthly Miscellaneous Income $ Total Income $ 2. Monthly Deductions (Mandatory and Voluntary) JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 1 of 7 Mandatory Deductions Cost Per Month Cost Per Month Federal Income Tax $ State/Local Income Tax $ PERA/Civil Service Social Security Tax Medicare Tax Other - ___________________ Total Mandatory Deductions $ Voluntary Deductions Cost Per Month Cost Per Month Life and Disability Insurance $ Stocks/Bonds $ Health, Dental, Vision Insurance Premium Total number of people covered on Plan  Retirement & Deferred Compensation Child Care (deducted from salary) Other - ____________________ Flex Benefit Cafeteria Plan Other - ____________________ Total Voluntary Deductions $ Total Monthly Deductions $ 3. Monthly Expenses Note: List regular monthly expenses below that you pay on an on-going basis and that are not identified in the deductions above. A. Housing Cost Per Month Cost Per Month 1 st Mortgage $ 2 nd Mortgage $ Insurance (Home/Rental) & Property Taxes (not included in mortgage payment) Condo/Homeowner’s/Maintenance Fees Rent Other - ________________ Total Housing $ B. Utilities and Miscellaneous Housing Services Cost Per Month Cost Per Month Gas & Electricity $ Water, Sewer, Trash Removal $ Telephone (local, long distance, cellular & pager) Property Care (Lawn, snow removal, cleaning, security system, etc.) Internet Provider, Cable & Satellite TV Other - ____________________ Total Utilities and Miscellaneous Housing Services $ C. Food & Supplies Cost Per Month Cost Per Month Groceries & Supplies $ Dining Out $ Total Food & Supplies $ D. Health Care Costs (Co-pays, Premiums, etc.) Cost Per Month Cost Per Month Doctor & Vision Care $ Dentist and Orthodontist $ Medicine & RX Drugs Therapist Premiums (if not paid by employer) Other - ____________________ Total Health Care $ E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 2 of 7 Cost Per Month Cost Per Month Primary Vehicle Payment $ Other Vehicle Payments $ Fuel, Parking, and Maintenance Insurance & Registration/Tax Payments (yearly amount(s)  12) Bus & Commuter Fees Other - ________________ Total Transportation $ F. Children’s Expenses and Activities Cost Per Month Cost Per Month Clothing & Shoes $ Child Care $ Extraordinary Expenses i.e. Special Needs, etc. Misc. Expenses, i.e. Tutor, Books, Activities, Fees, Lunch, etc. Tuition Other - ________________ Total Children’s Expenses and Activities $ G. Education for you - Please identify status:  Full-time student  Part-time student Cost Per Month Cost Per Month Tuition, Books, Supplies, Fees, etc. Other - ________________ Total Education $ H. Maintenance (Spousal/Partner Support) & C hild Support (that you pay) Cost Per Month Cost Per Month Maintenance Child Support  This family $  This family $  Other family  Other family Total Maintenance and Child Support $ I. Miscellaneous (Please list on-going expenses not covered in the sections above) Cost Per Month Cost Per Month Recreation/Entertainment $ Personal Care (Hair, Nail, Clothing, etc.) $ Legal/Accounting Fees Subscriptions (Newspapers, Magazines, etc.) Charity/Worship Movie & Video Rentals Vacation/Travel/Hobbies Investments (Not part of payroll deductions) Membership/Clubs Home Furnishings Pets/Pet Care Sports Events/Participation Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Other - ________________ Total Miscellaneous $ Total Monthly Expenses (Totals from A – I) $ 4. Debts (unsecured) JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 3 of 7 List unsecured debts such as credit cards, store charge accounts, loans from family members, back taxes owed to the I.R.S., etc. Do not list debts that are liens against your property, such as mortgages and car loans, because that payment is already listed as an expense above, and the total of the debt is shown elsewhere as a deduction from value where that asset is listed, such as under Real Estate or Motor Vehicles. For name on account, "P" = Petitioner, "C/R” = Co-Petitioner or Respondent, "J" = Joint. Name of Creditor Account Number (last 4- digits only) P C/R J Date of Balance Balance Minimum Monthly Payment Required Reason for Which Debt was Incurred    $ $                                           Unsecured Debt Balance $ $ → Total Minimum Monthly Payment SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES) Total Income (from Page 1) $ _____________ A Total Monthly Deductions (from Page 2) $ _____________ B Total Monthly Net Income (A minus B) $ _____________ Total Monthly Expenses (from Page 3) $ _____________ C Total Minimum Monthly Payment Required - Debts Unsecured (from Page 4) $ _____________ D Total Monthly Expenses and Payments (C plus D) $ _____________ Net Excess or Shortfall (Monthly Net Income less Monthly Expenses and Payments) (+/-) $ ______________ 5. Assets You MUST disclose all assets correctly. By indicating “None”, you are stating affirmatively that you or the other party, do not have assets in that category. Please attach additional copies of pages 5 & 6 to identify your assets, if necessary. JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 4 of 7 If the parties are married or partners in a civil union , check under the heading Joint (J) all assets acquired during the marriage/civil union but not by gift or inheritance. Under the headings of Petitioner (P) or Co- Petitioner/Respondent (C/R), check assets owned before this ma rriage/civil union and assets acquired by gift or inheritance. If the parties were NEVER married to each other or are using this form to modify child support , list all of each party’s assets under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R) . "P" = Petitioner, "C/R” = Co-Petitioner or Respondent, "J" = Joint. A. Real Estate (Address or Property Description and Name of Creditor/ Lender)  None P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed)    $ $ $       Total $ $ $ B . Motor Vehicles & Recreation Vehicles Including Motorcycles, ATV’s, Boats, etc.) (Year, Make, Model) (Name of Creditor/Lender)  None P C/R J Estimated Value as of Today Value = what you could sell it for in its current condition. Amount Owed Net Value/Equity (Value minus amount owed)             Total $ $ $ C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution)  None P C/R J Type of Account Account # (last 4-digits only) Balance as of Today    $          Total $ D. Life Insurance (Name of Company/Beneficiary)  None P C/R J Type of Policy Face Amount of Policy Cash Value today    $ $       Total $ $ E. Furniture, Household Goods, and Other Personal Property, i.e. Jewelry, Antiques, Collectibles, Artwork, Power Tools, etc. Identify Items and report in P C/R J Current Possession Held by Estimated Value as of Today Value = what you could sell itP C/R J JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 5 of 7 total.  None for in its current condition.       $                         Total $ F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts  None  If owned please attach JDF 1111-SS. Total $ G. Pension, Profit Sharing, or Retirement Funds  None  If owned please attach JDF 1111-SS. Total $ H. Miscellaneous Assets  None If you own any of the assets identified below, please check the appropriate box and attach JDF 1111-SS to report the value.  Business Interests  Stock Options  Money/Loans owed to you  IRS Refunds due to you  Country Club & Other Memberships  Livestock, Crops, Farm Equipment  Pending lawsuit or claim by you  Accrued Paid Leave (sick, vacation, personal)  Oil and Gas Rights  Vacation Club Points  Safety Deposit Box/Vault  Trust Beneficiary  Frequent Flyer Miles  Education Accounts  Health Savings Accounts  Mineral and Water Rights  Other - __________  Other - ___________  Other - _____________  Other - _____________ Total $ I. Separate Property  None  If owned please attach JDF 1111-SS to identify the property and to report the value. Total $ Total Value/Balance of All Assets (A – I) $  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. I understand that if the information I have provided changes or needs to be updated before a final decree or order is issued by the Court, that I have a duty to provide the correct or updated information. I understand that if I have omitted or misstated any material information, intentionally or not, the Court will have the power to enter orders to address those matters, including the power to punish me for any statements made with the intent to defraud or mislead the Court or the other party. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 6 of 7 (date) (month) (year) (city or other location, and state OR country _____________________________________ ____________________________________ (printed name of Petitioner or Co-Petitioner/Respondent) Signature of Petitioner or Co-Petitioner/Respo ndent CERTIFICATE OF SERVICE I certify that on ________________________ (date) a true and accurate copy of the SWORN FINANCIAL STATEMENT was served on the other party by:  Hand Delivery,  E-filed,  Faxed to this number: ___________________, or  By placing it in the United States mail, postage pre-paid, and addressed to the following: To: _______________________________________ _______________________________________ _______________________________________ ______________________________________ Your signature JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 7 of 7