Dissolution Of Marriage Declaration Form – Fill Out and Use This PDF

DISSOLUTION OF MARRIAGE FINANCIAL DECLARATION FORM

STATE OF INDIANA: CIRCUIT AND SUPERIOR COURTS OF LAKE COUNTY

IN RE THE MARRIAGE OF:

Cause Number:

Wife

and

Husband

FINANCIAL DECLARATION OF

Dated:

This declaration is considered mandatory discovery and must be exchanged between the parties within 60 days of the initial filing of the Dissolution of Marriage. Parties not represented by counsel are required to comply with these practices. Failure by either party to complete and exchange this form as required will authorize the court to impose sanctions set forth in Rule 6 of the Lake County Rules of Family Law. If appraisals or verifications are not available within 60 days the from must be exchanged within 60 days with a notation that appraisals or verifications are being obtained and then the Declaration shall be supplemented within 30 days thereafter.

Husband:

Wife:

Address:

Address:

Soc. Sec. No.:

Soc. Sec No.:

Badge/Payroll No.:

Badge/Payroll No.:

Occupation:

Occupation:

Employer:

Employer:

Date started this employment:

Date started this employment:

Birth Date:

Birth Date:

Date of Marriage:

Date of Physical Separation:

Date of Filing:

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	List Names, dates of birth, and social security numbers of all children of this
relationship, whether by birth or adoption:
Name:			DOB:		SSN:
Name:			DOB:		SSN:
Name:			DOB:		SSN:

List Names and dates of birth of any other children living at the residence of the person responding (identify if these are children of the responding party) and for each such person indicate the amount of support, if any, that is received:

Name:			DOB:			Support:
Name:			DOB:			Support:

Part I. INCOME AND EXPENSES STATEMENT

Attach COMPLETE copies of your Federal Income Tax Returns for the last three taxable years including all W2's and 1099's. Also attach proof of all wages earned in the present year up to the date of your response. If current wage statement shows year to date wages and itemized deductions this is sufficient. If current wage statement does not indicate year to date earnings and deductions attach the 8 most recent pay stubs.

PERSON RESPONDING

A.Gross yearly income from Salary and Wages, including commissions, bonuses, allowances and overtime, received in most recent year.

Average gross pay per pay period (indicate whether

you are paid weekly each 2 weeks, monthly or twice per month)

B. Gross Monthly Income From Other Sources1

List and explain in detail any Rents received, Dividend income, or Pension, Retirement, Social Security, Disability and/or Unemployment Insurance benefits - or any other source including Public assistance, food stamps, and child support received for any child not born of the parties of this marriage.

Source:Amount:

1Some of these items may not apply to support or maintenance computations.

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C.SELECTED LIVING EXPENSES: List names and relations of each member of the household of the Responding party whose expenses are included.

Name:Relationship:

For each expense attach verification of payment even if it is not specifically requested on this form - please note that Indiana uses an Income Shares model for determining support and thus in most cases the expenses that a party has or does not have are not relevant in determining support under the Indiana Support Guidelines. However if you claim your expenses justify a deviation from the support guidelines attach a detailed list of expenses together with verification of same.

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D.IN ALL CASES INVOLVING CHILD SUPPORT: Prepare and attach any Indiana Child Support Guideline Worksheet (with documentation verifying your income); or, supplement with such a Worksheet within ten (10) days of the exchange of this Form.

Further, if there exists a parenting plan or pattern then state the number of overnights the non-custodial parent will have the child during the year.

The yearly number of overnights is

E.POST HIGH SCHOOL EDUCATION EXPENSE

If any of the children subject to this case are attending post high school classes, or will attend within the next six months list the following information for each such student.

Further attach to this financial affidavit any documentation you have in support of these answers.

Name of Student:

Name of School:

Cost of School per year:

Room and Board (if applicable):

Identify all student financial aid including grants, scholarships, and loans and for each indicate what it is and how much will be received:

Note in those cases where it is appropriate parties may want to engage in additional discovery concerning assets that might be applied to education such as IRA’s, 401 K’s etc. Note further that withdrawals from IRA’s for educational expenses do not suffer a 10%

penalty (IRC code sec 72 (t) 2 (e).

F. Debts And Obligations: (Include credit union) attach additional sheets as needed. Indicate any special circumstances, i.e., premarital debts, debts in arrears on the date of physical separation, or date of filing and the amount or number of payments in arrears.

ATTACH A COPY OF THE MOST RECENT STATEMENT FOR EACH LISTED DEBT

Creditor’s Name		Persons on		Balance		Monthly Payment
		Account

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PART II. NET WORTH - ATTACH ALL AVAILABLE DOCUMENTATION TO VERIFY VALUES –

List all property owned either individually or jointly. Indication who holds or how the title is held: (H) Husband, (W) Wife, or (J) Jointly or other appropriate indication. WHERE SPACE IS INSUFFICIENT FOR COMPLETE INFORMATION OR LISTING PLEASE ATTACH SEPARATE PAGE.

A.Household Furnishings: (Value of Furniture, Appliances, and Equipment, as a whole - You need not itemize - indicate whether you use replacement cost or “garage sale” value)

B.Automobiles, Boats, Snowmobiles, Motorcycles, Etc.:

Automobile/Driver		Ownership		Value		Balance Owed/Creditor

Source for value: Kelley Blue Book

C. Cash and Deposit Accounts: (including ALL banks, savings and loan associations,

credit unions, thrift plans, mutual funds, certificate of deposit, savings and/or checking accounts, IRA’s and annuities). This also includes listing the contents of any safety

deposit boxes. Use additional page if necessary.

Name of Institution		Owner(s)		Account No.		Balance
Type of Account

Note: See Retirement section for IRA information.

D.Securities: (Stocks, Bonds, Etc) - use additional page if necessary

Company Name		Owner(s)		Shares		Account No.		Value

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F.Retirement Plans: List monthly amount you would be entitled to at earliest retirement date (indicating that date) if you stopped work today. Your response should indicate date of valuation. Further, if it is a defined interest plan list present amount in plan and date of valuation.

Also, identify whose plan it is and list both the name and the address of administrator of plan - indicate whether plan is vested - if not vested, indicate when it will vest:

Name of Plan		Ownership		Vested		Monthly		Present Value
						Benefit

Attach documents from each plan verifying information. If not yet received, attach a copy of your written request to the plan(s).

G.Life Insurance: Give name of insured, beneficiary, company issuing, policy #, type of insurance (term, whole life, group), face value, cash value and any loans against - include plans provided by employer:

Company		Ownership		Beneficiary		Face		Type		Cash Value
Name						Amount				Loan Amount
Policy No.

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PART III. VERIFICATION

I declare, under the penalty of perjury, that the foregoing, including any valuations and attachments, is true and correct and that I have made a complete and absolute disclosure of all of my assets and liabilities. Furthermore, I understand that if, in the future, it is proven to this court that I have intentionally failed to disclosure any asset or liability, I

may lose the asset and may be required to pay the liability. Finally, I acknowledge that sanctions may be imposed against me, including reasonable attorney’s fees and expenses

incurred in the investigation, preparation and prosecution of any claim or action that proves my failure to disclose income, assets or liabilities.

DATE: _________________

PARTY’S SIGNATURE

PART IV. ATTORNEY’S CERTIFICATION

I have reviewed with my client the foregoing information, including any valuations and attachments, and sign this certificate consistent with my obligation under Trial Rule 11 of the Indiana Rules of Procedure.

DATE:

AFFIDAVIT OF SERVICE
I, affirm under the penalties of perjury that on the ________ day of _______________________,	,

service of a true and complete copy of the above and foregoing pleading or paper was made upon each party or attorney of record herein by depositing the same in the United States Mail in envelopes properly addressed to each of them and with sufficient first class postage affixed.

BY:______________________________________

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