Free My Name Address City, State, Zip Phone E-mail I am the Petitioner Respondent Att... - Utah

My Name Address City, State, Zip Phone E-mail I am the Petitioner Respondent Attorney for the _______

Petitioner

Respondent and my Utah Bar number is

In the District Court of Utah __________ Judicial District ________________ County Court Address ______________________________________________________ _____________________________________ Financial Declaration Petitioner Case Number ___________________ v. Judge _________________________ _____________________________________ Commissioner ___________________ Respondent
Instructions: You must attach the following records and forms.

Continuation pages (If any, completing paragraphs that don't have enough space. Write the paragraph number on the continuation page.) Records supporting every item listed (Suggested records are listed with each paragraph. You should delete all but the last 4 digits of account numbers.) By and through my attorney, (Attorney, check here if you are appearing on behalf of your
client.)

I say as follows: (1) I declare under criminal penalty of Utah Code Section 78B-5-705 that:

Financial Declaration

Approved Board of District Court Judges September 10, 2008

Page 1 of 11

· · · (2)

the information in this Financial Declaration about myself is true and correct; the information about the other party is true and correct or is an estimate to the best of my information and belief, and I have omitted nothing that is relevant to my financial status. Social Security Number. The last 4 digits of my Social Security Number are: _____________.

(3)

Employment Status. (A) I am employed by: Doing Business As (DBA) Address

Name of Employer

(B)

I am self employed by:

Name of Employer

Doing Business As (DBA)

Address

(C) (4)

I am unemployed.

Monthly Income. (If only one party receives income in a category, enter the amount in that party's column and enter $0 in the other party's column. Attach evidence of items listed, such as most recent pay stubs, tax returns, W-2 forms, or a work history report from the Department of Workforce Services.) Petitioner's Income $ $ Rental Income Source of Income Work (Including self employment, wages, salaries,
commissions, bonuses, and tips)

Respondent's Income $ $

Financial Declaration

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Petitioner's Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Source of Income Business Income Interest and Dividends Retirement Income (Including pensions, 401(k), IRA,
etc.)

Respondent's Income $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Worker's Compensation Social Security Disability (SSDI and SSI) Private Disability Insurance Social Security (Do not include SSDI or SSI) Unemployment Benefits Education Benefits Veteran's Benefits Alimony Child Support Payments from Civil Litigation Victim Restitution Public Assistance (Including AFDC, welfare, etc.) Support from household members Support from non-household members Other (Describe) Other (Describe) Total I have no income because:

(5)

Monthly Deductions. (If only one party has a deduction in a category, enter the amount in that party's column and enter $0 in the other party's column. Attach evidence of claims, such as most recent pay stubs, tax returns, W-2 forms, or a work history report from the Department of Workforce Services.)

Financial Declaration

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Petitioner's Deductions $ $ $ $ $ $ $ $ $ $ $ (6) Net Income. Petitioner $ (7)
documents, etc.)

Type of Deduction Federal Income Tax State Income Tax FICA Health Insurance Premiums Life Insurance Premiums Union and other dues Garnishment or Income Withholding Order Retirement Deposits (Including pensions, 401(k),
IRA, etc.)

Respondent's Deductions $ $ $ $ $ $ $ $ $ $ $

Other (Describe) Other (Describe) Total

Respondent Income (from (4)) minus Deductions (from (5)) $

Real Property. (Attach evidence of items listed, such as mortgage statements, loan Mortgage or Lien Holder

Property Home (Address)

(Name & Address)

In Whose Name?
Petitioner Respondent Both

Current Value

Amount Owed

Monthly Payments

$ Other Real Property (Address)
Petitioner Respondent Both

$

$

$

$

$

Financial Declaration

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Mortgage or Lien Holder Property Other Real Property (Address)
(Name & Address)

In Whose Name?
Petitioner Respondent Both

Current Value

Amount Owed

Monthly Payments

$ (8)

$

$

Personal Property. (Attach evidence of items listed, such as receipts, loan documents, etc) Lien Holder
(Name & Address)

Property (Such as vehicles, boats, trailers, major equipment, etc.) Vehicle (Year, Make, Model)

In Whose Name?
Petitioner Respondent Both

Current Value

Amount Owed

Monthly Payments

$ Vehicle (Year, Make,
Model) Petitioner Respondent Both

$

$

$ Other (Describe)
Petitioner Respondent Both

$

$

$ Other (Describe)
Petitioner Respondent Both

$

$

$ Other (Describe)
Petitioner Respondent Both

$

$

$

$

$

Financial Declaration

Approved Board of District Court Judges September 10, 2008

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(9)

Business interests. Business Name Address & Phone Nature of Business Percent Owned By
___% Petitioner ___%Respondent

Current Value

Monthly Payments

$
___% Petitioner ___%Respondent

$

$ (10)

$

Financial Assets. (Attach evidence of items listed, such as bank statements, contracts, etc.) Holder Asset
(Name & Address)

In Whose Name?
Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both

Current Value

Bank or Credit Union Account
Last 4 digits of acct number: _________

$

Bank or Credit Union Account
Last 4 digits of acct number: _________

$

Stocks, Bonds, Securities, Money Market Fund
Last 4 digits of acct number: _________

$

Stocks, Bonds, Securities, Money Market Fund
Last 4 digits of acct number: _________

$

Retirement Account (Pension,
401(k), IRA, etc.) Last 4 digits of acct number: _________

$

Retirement Account (Pension,
401(k), IRA, etc.) Last 4 digits of acct number: _________

$

Financial Declaration

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Holder Asset Profit Sharing Plan
Last 4 digits of acct number: _________ (Name & Address)

In Whose Name?
Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both

Current Value

$

Profit Sharing Plan
Last 4 digits of acct number: _________

$

Annuity
Last 4 digits of acct number: _________

$

Annuity
Last 4 digits of acct number: _________

$

Money Owed to Parties

$

Cash

$

Other (Describe)

$
Face Value $__________ Cash Value $__________ Face Value $__________ Cash Value $__________

Life Insurance
Last 4 digits of acct number: _________

Life Insurance
Last 4 digits of acct number: _________

Financial Declaration

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(11)

Debts. (Do not include amount owed on property reported in Paragraphs (7) and (8). (Attach evidence of items listed, such as credit card statements, loan documents, leases, bills, etc.) Purpose of Debt (Such Debt Owed To
(Name & Address) as credit card, cash loan, installment payment, etc.)

In Whose Name?
Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both

Amount Owed

Monthly Payments

$

$

$

$

$

$

$

$

$

$

$

$

(12)

Monthly Expenses. (If only one party has an expense, enter the amount in that party's column and enter $0 in the other party's column. Attach evidence of items listed, such as credit card statements, loan documents, leases, bills, receipts, etc.) Petitioner's Expenses $ $ $ $ $ $ $ $ Monthly Expense Rent or mortgage Food and Household Supplies Clothing Transportation (Such as public transportation,
automobile payments, insurance, gas, maintenance) Utilities (Such as electricity, gas, water, sewer, garbage)

Respondent's Expenses $ $ $ $ $ $ $ $

Telephone Credit Card Payments Alimony

Financial Declaration

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Petitioner's Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ (13)

Monthly Expense Child Support Child Care Education Health Care Insurance (Excluding premium
deductions listed in Paragraph (5)) Health Care Expenses (Excluding insurance listed above or in Paragraph (5))

Respondent's Expenses $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Real Property Taxes Real Property Insurance Real Property Maintenance Other Insurance (Describe) Entertainment Laundry and Dry Cleaning Donations Gifts Other (Describe) Other (Describe) Total

Dependents. Dependents claimed on income tax return. (Attach tax return.) Name
(If person is under 18, use only initials)

Relationship to Age Petitioner Respondent Claimed By
Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both Petitioner Respondent Both

Financial Declaration

Approved Board of District Court Judges September 10, 2008

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I declare under criminal penalty of Utah Code Section 78B-5-705 that this Financial Declaration is true and correct, to the best of my information and belief, and that I have omitted nothing that is relevant to my financial status.
Date Sign here Typed or printed name

Certificate of Service
I certify that I served a copy of this Financial Declaration on the following people. Served at this Person's Name Method of Service Address Mail Hand Delivery Fax (Person agreed to service by fax.) Email (Person agreed to service by email.) Left at business (With person in charge
or in receptacle for deliveries.)

Served on this Date

Left at home (With person of suitable age (Other Party or Attorney)
and discretion residing there.)

(Clerk of Court)

Mail Hand Delivery Electronic File Mail Hand Delivery Fax (Person agreed to service by fax.) Email (Person agreed to service by email.) Left at business (With person in charge
or in receptacle for deliveries.)

Left at home (With person of suitable age
and discretion residing there.)

Financial Declaration

Approved Board of District Court Judges September 10, 2008

Page 10 of 11

Certificate of Service
I certify that I served a copy of this Financial Declaration on the following people. Served at this Person's Name Method of Service Address Mail Hand Delivery Fax (Person agreed to service by fax.) Email (Person agreed to service by email.) Left at business (With person in charge
or in receptacle for deliveries.)

Served on this Date

Left at home (With person of suitable age
and discretion residing there.)

Date

Sign here Typed or printed name

Financial Declaration

Approved Board of District Court Judges September 10, 2008

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