STATE OF SOUTH CAROLINA



STATE OF SOUTH CAROLINA) IN THE FAMILY COURT OF THE ) FORMTEXT ????? JUDICIAL CIRCUITCOUNTY OF FORMTEXT ?????)) FORMTEXT ?????)FINANCIAL DECLARATION Plaintiff,) OF FORMTEXT ?????vs.) FORMTEXT ?????) Defendant.)Docket No. FORMTEXT ?????HUSBAND/FATHERWIFE/MOTHERAddress FORMTEXT ?????Address FORMTEXT ?????Age FORMTEXT ?????Age FORMTEXT ?????Occupation FORMTEXT ?????Occupation FORMTEXT ?????Employer FORMTEXT ?????Employer FORMTEXT ?????Employer Address FORMTEXT ?????Employer Address FORMTEXT ?????Gross Monthly IncomeHusband/FatherWife/MotherPrincipal Earnings from Employment FORMTEXT ????? FORMTEXT ?????Overtime, Tips, Commission, Bonuses FORMTEXT ????? FORMTEXT ?????Pensions, Retirement, and Annuities income FORMTEXT ????? FORMTEXT ?????Additional Employment income FORMTEXT ????? FORMTEXT ?????Social Security Benefits (SSA) and VA Benefits FORMTEXT ????? FORMTEXT ?????Disability and Worker’s Compensation Benefits FORMTEXT ????? FORMTEXT ?????Unemployment and AFDC FORMTEXT ????? FORMTEXT ?????Spousal or Child Support (from other marriage/relationship) FORMTEXT ????? FORMTEXT ?????Dividends, Interest, Trust Income, and Capital Gains FORMTEXT ????? FORMTEXT ?????Rental Income and Business Profits FORMTEXT ????? FORMTEXT ?????Other (Specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL GROSS MONTHLY INCOME FORMTEXT ????? FORMTEXT ?????Payroll Deductions from Monthly IncomeHusband/FatherWife/MotherFederal Income Tax FORMTEXT ????? FORMTEXT ?????State Income Tax FORMTEXT ????? FORMTEXT ?????Social Security and Medicare Tax (FICA) FORMTEXT ????? FORMTEXT ?????Self-Employment Tax FORMTEXT ????? FORMTEXT ?????Health and Dental Insurance (Adult) FORMTEXT ????? FORMTEXT ?????Health and Dental Insurance (Child) FORMTEXT ????? FORMTEXT ?????Union Dues FORMTEXT ????? FORMTEXT ?????Voluntary Retirement Contribution (401(k), 457, IRA) FORMTEXT ????? FORMTEXT ?????Mandatory Retirement Contribution FORMTEXT ????? FORMTEXT ?????Savings Plan FORMTEXT ????? FORMTEXT ?????Other (Specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL MONTHLY DEDUCTIONS FORMTEXT ????? FORMTEXT ?????NET MONTHLY INCOME FORMTEXT ????? FORMTEXT ?????Estimate monthly expenses: (Specify which party is the custodial parent and list name and relationship of all members of household whose expenses are included. FORMTEXT ?????MONTHLY EXPENSES Husband/FatherWife/MotherResidential Rent Payment FORMTEXT ????? FORMTEXT ?????Note or Mortgage Payment on Residence(s) FORMTEXT ????? FORMTEXT ?????Food and Household Supplies FORMTEXT ????? FORMTEXT ?????Utilities, Water, and Garbage Collection FORMTEXT ????? FORMTEXT ?????Telephone and Cellular Phone FORMTEXT ????? FORMTEXT ?????Medical, Dental and Disability Insurance Premiums (not deducted from paycheck) FORMTEXT ????? FORMTEXT ?????Life Insurance Premiums (not deducted from paycheck) FORMTEXT ????? FORMTEXT ?????Child Support (from other relationship) FORMTEXT ????? FORMTEXT ?????Work Related Day Care FORMTEXT ????? FORMTEXT ?????Spousal Support (from prior marriage) FORMTEXT ????? FORMTEXT ?????Auto Payment FORMTEXT ????? FORMTEXT ?????Auto Insurance, taxes, gasoline, and maintenance FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SUBTOTAL: Real Property Tax on Residence(s) FORMTEXT ????? FORMTEXT ?????Maintenance for household FORMTEXT ????? FORMTEXT ?????Adult Clothing FORMTEXT ????? FORMTEXT ?????Children’s Clothing FORMTEXT ????? FORMTEXT ?????Cable Television, Satellite, and Internet/Online Services FORMTEXT ????? FORMTEXT ?????Laundry and Dry Cleaning FORMTEXT ????? FORMTEXT ?????Medical and Dental Expenses (not paid by insurance) FORMTEXT ????? FORMTEXT ?????Prescriptions, Glasses, and Contacts (not paid by insurance) FORMTEXT ????? FORMTEXT ?????Children’s incidental expenses FORMTEXT ????? FORMTEXT ?????School lunches, supplies, field trips, and fees FORMTEXT ????? FORMTEXT ?????Entertainment FORMTEXT ????? FORMTEXT ?????Adult Incidental expenses FORMTEXT ????? FORMTEXT ?????All Installment payments FORMTEXT ????? FORMTEXT ?????Other (Specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SUBTOTAL: TOTAL MONTHLY EXPENSES FORMTEXT ????? FORMTEXT ?????Installment Loan Payments SectionCreditorForMonthly PaymentBalanceOwed by FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Debts and Obligations not payable in monthly installmentsCreditorForDate PayableBalanceOwed by 16 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Are you currently in Bankruptcy? FORMCHECKBOX YES FORMCHECKBOX NOAre any obligations listed above, including mortgage and note payments, in arrears? FORMCHECKBOX YES FORMCHECKBOX NOIf yes, please list the obligations in arrears. FORMTEXT ?????All Marital Property Known to PartiesAssetsHusband/FatherWife/MotherJointCash and Money in Checking Account(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Money in Savings Account(s), Credit Union, Money Market, or Cert. of Dep. FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of Voluntary Retirement Account(s) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of Pension Account FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of Publicly Held Stocks, Bonds, Securities, Mutual Funds FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of Privately Held Stocks and Other Business FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of Real Estate – Net of Mortgage Balances FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Value of All Other Property17 FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????TOTAL ASSETS FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? Any Non Marital Property Known to PartiesDescription of AssetTitle OwnerDate of AcquisitionSource of Funds to AcquirerEstimate Present market Value FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If total assets are less than $300,000.00, sign and have notarized.If total assets are greater than $300,000.00, itemize assets by completing additional sections below and sign and have notarized.Financial Accounts Section18OwnerName of InstitutionType of AccountBalance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Voluntary Retirement Accounts and Pension Accounts SectionType of AccountValue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Publicly Held Stocks, Bonds, Securities, Mutual Funds Section (Non-Retirement)19Name of CompanyNumber of Shares/Type of AccountValue FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Real Estate Section20OwnerAddressValueMortgage BalanceMortgage Equity FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Property Section17OwnerDescription of AssetValueLoan BalanceEquity FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????___________________________________________SignatureSworn to before me this FORMTEXT ????? of FORMTEXT ?????, 2 FORMTEXT ?????. _________________________________ (SEAL)Notary Public for South CarolinaMy commission expires: ____________Custodial Parent (if applicable): FORMTEXT ????? ................
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