Form Scca 430S – Fill Out and Use This PDF

STATE OF SOUTH CAROLINA

)

IN THE FAMILY COURT OF THE

COUNTY OF

)

JUDICIAL CIRCUIT

)

)

SHORT FORM

Plaintiff

)

FINANCIAL DECLARATION

vs

)

OF

)

(FOR USE ONLY IN CHILD SUPPORT ENFORCEMENT

)

AND WITH PETITION FOR ORDER OF PROTECTION)

)

Defendant

)

Docket No.

Address

Age

Occupation

Employer

Employer Address

Gross Monthly Income

Amount:

Monthly Expenses

Amount:

(have proof of expenses available)

1)

Earnings (attach recent pay stubs)

1)

Rent/Mortgage

2)

Overtime

2)

Utilities

3)

Social Security, VA Benefits

3)

Cell phone/Phone

Workers Comp or Disability (SSI)

4)

Food

4)

Unemployment

5)

Child Support/Alimony

5)

Alimony/Child Support

(outside of this case)

6)

Other (Specify)

6)

Child Care

(Add lines 1-6)

Total Amount:

7)

Car Payment

8)

Car Operating Expenses

(Insurance, gas, maintenance)

Assets

Amount:

9)

Clothing

10) Cable/Satellite TV/Internet

1)

Cash

11) Medical/Dental/Vision Expenses (self)

2)

Money in Bank accounts

12) Medical/Dental/Vision Expenses (child)

(Checking & Savings)

13) Medical/Dental/Vision Insurance (self)

3)

IRA/401K/Pensions

14) Medical/Dental/Vision Insurance (child)

4)

Other (Specify)

15)

Credit Card/Loan Payments

(Add lines 1-4)

Total Amount:

16) Other (Specify)

(Add lines 1-16)

Total Amount:

How many other biological children in the home?

Name(s) and Date(s) of Birth

Sworn to before me this _______ day

________________________________________

of _____________________, 20____

Signature

_______________________________________

Notary Public for South Carolina

My Commission Expires: __________________