Indiana Financial Form – Fill Out and Use This PDF

FINANCIAL DECLARATION FORM

STATE OF INDIANA: CIRCUIT AND SUPERIOR COURTS

OF PORTER COUNTY

IN RE THE MARRIAGE OF:

Cause Number:

Petitioner,

And

Respondent

In accordance with Local Rule 18 of the Porter Superior Court and Indiana Trial Rules 26, 33, 34, 35 and 37, the undersigned, Petitioner or Respondent, hereby submits the following

VERIFIED FINANCIAL DISCLOSURE STATEMENT:

FINANCIAL DECLARATION OF

Dated:

I. PRELIMINARY INFORMATION:

Husband:

Wife:

Address:

Address:

Soc. Sec. No.:

Soc. Sec No.:

Badge/Payroll No.:

Badge/Payroll No.:

Occupation:

Occupation:

Employer:

Employer:

Birth Date:

Birth Date:

Date of Marriage:

Date of Physical Separation:

Date of Filing:

Children:
Name:		Age:		DOB:		SSN:
Name:		Age:		DOB:		SSN:
Name:		Age:		DOB:		SSN:

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II. HEALTH INSURANCE INFORMATION:

Name and Address of health care insurance company:

Name all persons covered under plan(s):

Name of the children’s health care providers:

The names of the schools and grade level for each child are:

List any extraordinary health care concerns of any family member:

List any educational concerns of any family member:

III.INCOME INFORMATION:

A.EMPLOYMENT HISTORY:

Current Employer:

Address:

Telephone No.:						Length of Employment:
Job Description:
Gross Income:
		Per week		Bi-weekly				Per month			Yearly
Net Income:
		Per week		Bi-weekly				Per month			Yearly

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Union or other dues:

Retirement:

Pension fund: Mandatory ( )Optional ( )

Profit sharing: Mandatory ( )Optional( )

401(K): Mandatory ( ) Optional ( )

SEP: Mandatory ( ) Optional ( )

ESOP: Mandatory ( ) Optional ( )

IRA: Mandatory ( ) Optional ( )

403 B: Mandatory ( ) Optional ( )

Child Support withheld from pay (not including this case)

Garnishments (itemize on separate sheet)

Credit Union debts

Direct Withdrawals Out of Paychecks:

Car Payments

Life Insurance

Disability Insurance

Thrift plans

Credit Union Savings

Bonds

Donations

Other (specify)

Other (specify)

TOTAL WEEKLY DEDUCTIONS:

3. WEEKLY DISPOSABLE INCOME:

(A minus B: Subtract Total Weekly Deduction from Total Weekly Gross Income)

IN ALL CASES INVOLVING CHILD SUPPORT: Prepare and attach an 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.

IV. MONTHLY LIVING EXPENSES:

House

1.Rent (Mortgage)

2.2nd Mortgage

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3.Line of Credit

4.Gas/Electric

5.Telephone

6.Water

7.Sewer

8.Sanitation (garbage)

9.Cable

10.Satellite

11.Internet

12.Taxes (real estate – if not included in mortgage payment

13.Insurance (house – if not included in mortgage payment)

14.Lawn Care/Snow Removal

Groceries

1.Food

2.Toiletries

3.Cleaning Products

4.Paper Products

Clothing

1.Clothes

2.Shoes

3.Uniforms

Health Care

1.Health Insurance not deducted from pay

2.Dental Insurance not deducted from pay

3.Doctor visits (non-insurance covered)

4.Dental visits (non-insurance covered)

5.Prescription Pharmaceutical (non-insurance covered)

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6.Over-the-counter medicine

7.Glass/contact lenses

8.Other non-insurance covered health care (itemize)

Car & Travel

1.Car Payment

2.Gasoline

3.Oil/Maintenance

4.Insurance (car)

5.Car Wash

6.Tolls

7.Train/Bus

8.Parking Lot Fees

9.License Plates

Beauty Care

1.Hair Dress/Barber

2.Cosmetics

School Needs

1.Lunches

2.Books

3.Tuition/Registration

4.Uniforms

5.School Supplies

6.Extra-Curricular Activities

Infant Care

1.Diapers

2.Baby Food

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Miscellaneous

1.Church Donations

2.Charitable Donations

3.Life Insurance

4.Babysitter

5.Newspapers & Magazines

6.Cigarettes

7.Dry Cleaning

8.Entertainment

9.Cell Phone

10.Dues/Subscriptions

11.Charge Cards

12.Other (specify)

SUB-TOTAL OF EXPENSES:

Average Weekly Expenses (multiply monthly expenses by 12 and divide by 52)

V. PROVISIONAL ARREARAGE COMPUTATIONS:

If you allege the existence of a child support, maintenance, or other arrearage, attach all records or other exhibits regarding the payment history and complete the child support arrearage.

You must attach a Child Support Guideline Worksheet to your Financial Declaration Form or one must be exchanged with the opposing party/counsel within 10 days of receipt of the other parties= Financial Declaration Form.

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C.PERSONAL PROPERTY: (motor vehicles, boats, motorcycles, furnishings, household goods, jewelry, firearms, etc. Household furnishings and household goods such as pots and pans need not

be itemized).

VII. BANK ACCOUNTS:

VIII. NON-RETIREMENT SECURITIES: (stocks, bonds, mutual funds, etc.)

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IX. LIFE INSURANCE POLICIES (whole life, variable life, annuities, term)

X.RETIREMENT ACCOUNTS (Pension, Profit Sharing, 401(K), SEP, IRA, KEOGH, ESOP, etc.)

XI. OTHER PROFESSIONAL OR BUSINESS INTERESTS:

XII. MARITAL BILLS, DEBTS, AND OBLIGATIONS: (list every single bill, debt and obligation regardless of whether the bill is title in your name, your spouse=s name, or jointly. Please include all mortgages, 2nd mortgages, home equity loans, charge cards, other loans, credit union loans, car payments, and unpaid medical bills, etc. Do not include monthly expenses such as utilities that are paid in full every month).

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XIII. RECAPITULATION: A summary of the marital estate is as follows:

	ASSET:					In Name of Husband		In Name of Wife	Jointly held	Total
	Family Dwelling
	Other Real Estate
	Personal Property
	Bank Accounts
	Non-Retirement
	Securities
	Life Insurance
	Policies
	Retirement Accounts
	Other
	Professional/Business
	Interests
		Total Assets:
	LIABILITIES:
	General Creditors
	Mortgage on Family
	Dwelling
	Mortgages on Other
	Real Estate
	Notes to Banks and
	Others
	Loans on Insurance
	Policies
	Other liabilities
		Total of Liabilities:
		ASSETS MINUS
		LIABILITIES:

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XIV. PERSONAL STATEMENT REGARDING DIVISION OF PROPERTY:

Indiana law presumes that the marital property be split in a 50/50 basis. However, the Judge may order a division which may differ from an exact 50/50 division of your property. Please provide a brief statement as to your reasons, if there be any, why the Court should divide or divide on anything other than a 50/50 basis.

XV. MANDATORY EXHIBITS:

The following exhibits must be attached to your Financial Declaration Form:

1.The last three years of Individual State and Federal income tax returns together with all W-2 forms, 1099 forms, and K-1 forms.

2.The immediate preceding six paycheck stubs showing year-to-date earnings.

3.Documents showing the amount of income received from any other source in the past three years including irregular income in an amount greater than $500 per year plus any expenses relating thereto.

4.Child support worksheet, if applicable.

5.Arrearage calculation, if application under V of this Financial Declaration Form.

6.With regard to all real estate listed under VI (A) and (B):

a..The title insurance policy, if available, b. The deed,

c. An amortization schedule from the lending institution, if available,

d.Documents showing the mortgage balance as of the date of the filing of the Petition for Dissolution of Marriage.

7.As to all bank accounts identified in VII of this Financial Declaration Form:

a.Copy of the bank statement closest to the date of the filing of the Petition for Dissolution of Marriage.

b.Copies of the bank statements for the five months immediately preceding the filing of the Petition for Dissolution of Marriage.

8.As to all Non-retirement Securities identified in VIII of this Financial Declaration Form:

a.Copy of the statement closest to the date of the filing of the Petition for Dissolution of Marriage, and

b.Copies of the statements for the five months immediately preceding the filing of the Petition for Dissolution of Marriage.

9.As to all Life Insurance policies identified in IX of this Financial Declaration Form attach statements as of cash value as of the date of the filing of the Petition for Dissolution of Marriage.

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