Free District Court Denver Juvenile Court _________________________________ County, C... - Colorado


File Size: 396.2 kB
Pages: 6
Date: July 10, 2006
File Format: PDF
State: Colorado
Category: Court Forms - State
Author: b888hb
Word Count: 1,614 Words, 11,825 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.courts.state.co.us/Forms/PDF/jdf1111.pdf

Download District Court Denver Juvenile Court _________________________________ County, C... ( 396.2 kB)


Preview District Court Denver Juvenile Court _________________________________ County, C...
District Court Denver Juvenile Court _________________________________ County, Colorado Court Address: In re: The Marriage of: Parental Responsibilities concerning:
______________________________________________________

Petitioner: and Co-Petitioner/Respondent: Attorney or Party Without Attorney (Name and Address):

COURT USE ONLY Case Number:

Phone Number: FAX Number:

E-mail: Atty. Reg. #:

Division

Courtroom

SWORN FINANCIAL STATEMENT
I, ___________________________________________________ (full name) I am employed ____ hours per week. I am paid My pay is based on a Monthly Salary weekly bi-weekly am am not currently employed. monthly. twice a month

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) for Petitioner $ ___________, Co-Petitioner/Respondent $ _____________

1.

Monthly Income (Convert annual, bi-monthly, and weekly amounts to monthly amounts.) $ Social Security Benefits (SSA) SSDI (Disability insurance entitlement
program) SSI (supplemental income need based)

Gross Monthly Income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, selfemployment, business income, other jobs, and monthly reimbursed expenses. Unemployment & Veterans' Benefits Pension & Retirement Benefits Public Assistance (TANF)

$

Disability, Workers' Compensation Interest & Dividends Other - ___________________

Total Monthly Income Miscellaneous Income
Royalties, Trusts, and Other Investments Dependent Children's monthly gross income. Source of Income: __________ Rental Net Income Child Support from Others Spousal Support from Others $ Contributions from Others All other sources, i.e. personal injury settlement, non-reported income, etc. Expense Accounts Other - ___________________ Other - ___________________

$
$

Total Monthly Miscellaneous Income

$ $

Total Income
JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2 Page 1 of 6

2. Monthly Deductions (Mandatory and Voluntary)
Mandatory Deductions Federal Income Tax PERA/Civil Service Medicare Tax Voluntary Deductions Life and Disability Insurance
Health, Dental, Vision Insurance Premium Total number of people covered on Plan

Cost Per Month $ State/Local Income Tax Social Security Tax Other - ___________________ $

Cost Per Month

Total Mandatory Deductions
Cost Per Month $ Stocks/Bonds Retirement & Deferred Compensation Other - ____________________ Other - ____________________

$ Cost Per Month $

Child Care Flex Benefit Cafeteria Plan

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 1st Mortgage Insurance (Home/Rental) & Property Taxes (not included in mortgage payment) Rent Cost Per Month $ 2nd Mortgage Condo/Homeowner's/Maintenance Fees Other - ________________ Cost Per Month $

Total Housing
B. Utilities and Miscellaneous Housing Services Cost Per Month Gas & Electricity $ Telephone (local, long distance, cellular &
pager)

$ Cost Per Month

Water, Sewer, Trash Removal Property Care (Lawn, snow removal,
cleaning, security system, etc.)

$

Internet Provider, Cable & Satellite TV

Other - ____________________ $ Cost Per Month Dining Out

Total Utilities and Miscellaneous Housing Services
C. Food & Supplies Cost Per Month Groceries & Supplies $

Total Food & Supplies
D. Health Care Costs (Co-pays, Premiums, etc.) Cost Per Month Doctor & Vision Care $ Medicine & RX Drugs Premiums (if not paid by employer)

$ $ Cost Per Month

Dentist and Orthodontist Therapist Other - ____________________

$

Total Health Care
JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2 Page 2 of 6

$

E. Transportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.) Cost Per Cost Per Month 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 Clothing & Shoes Extraordinary Expenses i.e. Special Needs, etc. Tuition $ Child Care Misc. Expenses, i.e. Tutor, Books, Activities, Fees, Lunch, etc. Other - ________________

$ Cost Per Month $

Total Children's Expenses and Activities
G. Education for you - Please identify status: Full-time student Part-time student Cost Per Month Tuition, Books, Supplies, Fees, etc. Other - ________________

$

Cost Per Month $ Cost Per Month

Total Education
H. Maintenance & Child Support (that you pay) Cost Per Month Spousal Maintenance This family Other family $

Child Support This family Other family $ $ Cost Per Month $

Total Maintenance and Child Support
I. Miscellaneous (Please list on-going expenses not covered in the sections above) 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)

JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2

Page 3 of 6

4.

Debts (unsecured)

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 4digits only) P C/R J Date of Balance Balance Minimum Monthly Payment Required Principal Purchase(s) for Which Debt Was Incurred

$

$

Unsecured Debt Balance

$

$

Total
Minimum Monthly Payment

SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES)
Total Income (from Page 1) Total Monthly Deductions (from Page 2) $ _____________ $ _____________ A B

Total Monthly Net Income (A minus B)
Total Monthly Expenses (from Page 3) Total Minimum Monthly Payment Required - Debts Unsecured (from Page 4)

$ _____________
$ _____________ $ _____________ C D

Total Monthly Expenses and Payments

(C plus D)

$ _____________

Net Excess or Shortfall (Monthly Net Income less Monthly Expenses and Payments)

(+/-)

$ ______________

JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2

Page 4 of 6

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.

If the parties are married, check under the heading Joint (J) all assets acquired during the marriage but not by
gift or inheritance. Under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R), check assets owned before this marriage 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)

P

C/R

J

Amount Owed

Estimated Value as of Today.
Value = what you could sell it for in its current condition.

Net Value/Equity

None
$

$

$

Total
B. Motor Vehicles & Recreation

$

$ Amount Owed Estimated Value as of Today.
Value = what you could sell it for in its current condition.

$ Net Value/Equity

Vehicles Including Motorcycles, ATV's, Boats, etc.) (Year, Make, Model) (Name of
Creditor/Lender)

P

C/R

J

None

Total C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution)

$ Type of Account

$ Account # (last 4-digits only)

$ Balance as of Today

P

C/R

J

None
$

Total D. Life Insurance (Name of Company/Beneficiary)

$ Cash Value today $

P

C/R

J

Type of Policy

Face Amount of Policy $

None

Total

$

$

JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2

Page 5 of 6

E. Furniture, Household Goods, and Other Personal Property, i.e. Jewelry, Antiques, Collectibles, Artwork, Power Tools, etc. Identify Items and report in total.

P

C/R

J

Current Possession Held by

P

C/R

J

Estimated Value as of Today.
Value = what you could sell it for in its current condition.

None

$

Total F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts None If owned please attach JDF 1111-SS. G. Pension, Profit Sharing, or Retirement Funds None If owned please attach JDF 1111-SS. Total 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 Country Club & Other Memberships Oil and Gas Rights Frequent Flyer Miles Other - __________ I. Stock Options Livestock, Crops, Farm Equipment Vacation Club Points Education Accounts Other - ___________ Money/Loans owed to you Pending lawsuit or claim by you Safety Deposit Box/Vault Health Savings Accounts Other - _____________ IRS Refunds due to you Accrued Paid Leave (sick, vacation, personal) Trust Beneficiary Mineral and Water Rights Other - _____________ Total 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)

$

I swear or affirm under oath that this Sworn Financial Statement, attached schedules, and mandatory disclosures contain a complete disclosure of my income, expenses, assets, and debt as of the date of my signature. 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 this oath is made under penalty of perjury. 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. Date: ____________________________ _____________________________________________
Signature of Petitioner or Co-Petitioner/Respondent

Subscribed and affirmed, or sworn to before me in the County of ______________________, State of __________________, this ___________ day of _______________, 20______.
My Commission Expires: ___________________
JDF 1111 R7/06 SWORN FINANCIAL STATEMENT FORM 35.2

_________________________________________________
Notary Public/Deputy Clerk Page 6 of 6