Free IN THE SUPERIOR COURT FOR THE STATE OF ALASKA - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) )

CASE NO. FINANCIAL DECLARATION HUSBAND'S Date of Marriage: Date of Separation: (Divorce/dissolution cases only) WIFE'S

Husband: Date of Birth: Occupation: Present Employer and Employer's Address: Age:

Wife: Date of Birth: Occupation: Present Employer and Employer's Address: Age:

How long at this job? If you are employed, but expecting soon to become unemployed or change jobs, describe the change you expect, why and how it will affect your income. If currently unemployed, describe your efforts to find employment, how soon you expect to be employed and the pay you expect to receive.

How long at this job? If you are employed, but expecting soon to become unemployed or change jobs, describe the change you expect, why and how it will affect your income. If currently unemployed, describe your efforts to find employment, how soon you expect to be employed and the pay you expect to receive.

Page 1 of 5 DR-250 (9/07)(cs) FINANCIAL DECLARATION

PART A. 1.

INCOME AND EXPENSE STATEMENT

Husband

Wife

Gross monthly income from: Salary and wages (incl. commissions, bonuses and overtime) payable weekly/monthly/etc. Pensions and retirement .............................. Social Security.............................................. Disability and unemployment insurance....... Welfare/Alaska Temp. Assistance payments Child/spousal support from prior marriage ... Dividends and interest (including Native Corporation dividends and Alaska Permanent Fund dividends) ................... Rents ............................................................ All other sources: (Specify)

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

$ $ $ $ $ $

Total Monthly Income......... 2. Itemize monthly deductions from gross income: Income taxes ................................................ Social Security.............................................. Medicare Tax................................................ Unemployment insurance............................. Medical or other insurance ........................... Union or other dues...................................... Retirement or pension fund .......................... Savings plan................................................. Other: (Specify)

$ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $

Total Deductions................. 3. 4. Net monthly income ..............................................

Total monthly expenses: (specify which party is presently the custodial parent of any children of this marriage and list name and relationship of all members of the household whose expenses are included)

Page 2 of 5 DR-250 (9/07)(cs) FINANCIAL DECLARATION

4.

Total Monthly Expenses - Continued The court may require proof of expenses in the form of canceled checks, receipts or other documents. Husband Wife

Rent or mortgage payments (residence) ....................... Real Property taxes (residence) .................................... Maintenance (residence) ............................................... Food and household supplies ........................................ Utilities ........................................................................... Telephone ...................................................................... Laundry and cleaning..................................................... Clothing.......................................................................... Medical........................................................................... Dental............................................................................. Insurance (life, health, accident, etc.) ............................ Child care....................................................................... Child/spousal support payments from prior marriage .... School ............................................................................ Entertainment................................................................. Incidentals...................................................................... Transportation................................................................ Gas, oil, repair (auto) ..................................................... Auto payments ............................................................... Installment payment(s) (Itemize below) Creditor's Name For $ $ $ $ $ $ Other Monthly Expenses: (Specify) Balance Due

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $

Total Expenses.............. 5. Other debts and obligations: Creditor's Name For Date Payable

Balance Due Husband $ $ $ $ $ $ $ $ $ $ $ Wife

Total Other Debts..........
Page 3 of 5 DR-250 (9/07)(cs) FINANCIAL DECLARATION

$

6.

List the value of the following property belonging to the parties: Husband Cash on hand........................................................ Money in checking account(s)............................... Money in credit union account(s) .......................... Money in any other account(s) or deposits ........... Retirement or pension fund................................... Life insurance cash value...................................... Value of any stocks & bonds................................. Value of real estate ............................................... Value of all other property ..................................... Total Property................ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Wife

NOTE:

If this form is being filled out for a children's proceeding, omit Parts B and C, and complete Part D. PROPERTY STATEMENT (Divorce/dissolution cases only)

PART B.

There is no property subject to disposition by the court in this proceeding. All property otherwise subject to disposition by the court in this proceeding has been disposed of by written agreement of the parties or oral stipulation made in open court. The property subject to disposition by the court in this proceeding is: Description of assets and obligations $ $ $ $ $ $ $ $ $ $ $ $ Value of assets $ $ $ $ $ $ $ $ $ $ $ $ Amount of obligations

Page 4 of 5 DR-250 (9/07)(cs) FINANCIAL DECLARATION

PART C.

ATTORNEY'S FEES AND COST STATEMENT (Divorce/dissolution cases only) for costs, and

I have paid my attorney(s) $ for fees and $ my arrangement with my attorney for payment of fees and costs is as follows:

Attorney's Signature

Date

Party's Signature

Date

PART D.

HEALTH

I do do not have a disease or defect in my health which will affect my ability to earn a living and support myself in the foreseeable future. (If you do have such a disease or defect, please explain below. Any claim of disability or impaired earning capacity must be supported by a doctor's statement attached as an exhibit to this statement.)

SIGNATURES I swear (or affirm) that all the information given in this declaration is true.

Date

Signature of Declarant

Type or Print Name

Mailing Address

City Work Phone Home Phone Subscribed and sworn to or affirmed before me at on .

State

Zip

, Alaska,

(SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires:
Page 5 of 5 DR-250 (9/07)(cs) FINANCIAL DECLARATION