Financial Declaration

Utah Rule of Civil Procedure 26.1

Plaintiff/Petitioner Defendant/Respondent Plaintiff/Petitioner's Attorney Defendant/Respondent's Attorney Utah Bar #:

Name

Phone

Address

City, State, Zip

In the District Court of Utah
__________ Judicial District ________________ County
Court Address:

Petitioner v. Respondent

Case Number

Judge

Commissioner

Warning: You must fully and accurately disclose all assets and income in this document and provide attachments. If you fail to disclose all assets and income, you could be subject to sanctions under Utah Rule of Civil Procedure 37. Sanctions can include an award of non-disclosed assets to the other party, attorney's fees or other sanctions.

1. Filing Status (Choose one)

I am not filing the Financial Declaration with the court because a hearing about child support, spousal support, property, debts, attorney fees and court costs is not scheduled, or because the court has not ordered me to file it. I am filing the separate Certificate of Service of Financial Declaration. I am filing the Financial Declaration with the court because a hearing about child support, spousal support, property, debts, attorney fees and court costs is scheduled, or the court has ordered me to file it. I am also filing the separate Certificate of Service of Financial Declaration.

2. Attached Documents (if available)

Tax returns. For the two years before the petition was filed: federal and state income tax returns – personal and for any entities in which I have a majority or controlling interest; all documents used to prepare the tax returns. Attached Not attached Doesn't apply
Pay stubs or other proof of income. For the 12 months before the petition was filed: pay stubs; other proof of all earned and un-earned income. Attached Not attached Doesn't apply
Loan applications. For the 12 months before the petition was filed: all loan applications; financial statements used to apply for the loans. Attached Not attached Doesn't apply
Real estate documents. Documents verifying the value of all real estate in which I have an interest. This includes the most recent appraisal, tax valuation, and refinance documents. Attached Not attached Doesn't apply
Financial statements. For the 3 months before the petition was filed all financial statements for all financial accounts. This includes checking, savings, money market funds, certificates of deposit, brokerage, investment, and retirement. Attached Not attached Doesn't apply

I marked some documents above as "not attached" because:

Document	Reason

3. Employment (attach proof of amounts listed)

I am employed as (Choose all that apply):

an hourly employee (Form W-2) a salaried employee (Form W-2) self-employed (Form 1099, Form K-1, Schedule C, etc.) other (Explain):

Name of employer	Employer's address and phone number	Job title	Hourly rate or annual salary	Hours per week (If hourly)
			$
			$
			$

I am unemployed because:

I have estimated the amounts in paragraph 3.

Item estimated	Basis for estimation

4. Gross Monthly Income (attach proof of amounts listed)

I have the following monthly income before tax deductions:

Print your pre-tax income in the boxes below. For income that changes from month to month, calculate the annual total and divide by 12 months to list a monthly average.

Source of income	Monthly amount
Work (Including self employment, wages, salaries, commissions, bonuses, tips and overtime)	$
Rental income	$
Business income	$
Interest	$
Dividends	$
Retirement income (Including pensions, 401(k), IRA, etc.)	$
Worker's compensation	$
Private disability insurance	$
Social Security Disability Income (SSDI)	$
Supplemental Security Income (SSI)	$
Social Security (Other than SSDI or SSI)	$
Unemployment benefits	$
Education benefits (Including grants, loans, cash scholarships, etc.)	$
Veteran's benefits	$
Alimony	$
Child support	$
Payments from civil litigation	$
Victim restitution	$
Public assistance (Including AFDC, FEP, TANF, welfare, etc.)	$
Financial support from household members	$
Financial support from non-household members	$
Trust income	$
Annuity income	$
Other (Describe):	$
Other (Describe):	$
Total gross monthly income	$

I have estimated the amounts in paragraph 4.

Item estimated	Basis for estimation

I have no income because:

5. Monthly Tax Deductions (attach proof of amounts listed)

I have no monthly tax deductions because I have no income. I have the following monthly tax deductions.

Type of tax deduction	Amount
Federal income tax	$
State income tax	$
Municipal income tax	$
FICA	$
Medicare	$
Total monthly tax deductions	$

I have estimated the amounts in paragraph 5.

Item estimated	Basis for estimation

6. After Tax Income

My monthly income is:

                    $ Gross monthly income from section 4
                
                    -
                    $ Minus monthly tax deductions from section 5
                
                    =
                    $ Equals after-tax monthly income

I have no income.

7. Monthly Expenses (attach proof of amounts listed)

No party has requested alimony so I am only completing the "Current Amount" column, which represents the amount I pay now.

One of the parties has requested alimony so I am completing both the "Current Amount" and the "Marital Expenses" column, which represents the amount paid during the marriage prior to separation.

Monthly expense	Current Amount	Marital Expenses
Rent or mortgage	$	$
Real estate taxes (if not included in mortgage)	$	$
Real estate insurance (if not included in mortgage)	$	$
Real estate maintenance	$	$
Food and household supplies	$	$
Clothing	$	$
Automobile payments	$	$
Automobile insurance	$	$
Automobile fuel	$	$
Automobile maintenance	$	$
Other transportation costs (public transportation, parking, etc.)	$	$
Utilities (such as electricity, gas, water, sewer, garbage)	$	$
Telephone	$	$
Paid television, cable, satellite	$	$
Internet	$	$
Credit card payments	$	$
Loans and other debt payments	$	$
Alimony	$	$
Child support	$	$
Child care	$	$
Extracurricular activities for children	$	$
Education (children)	$	$
Education (self)	$	$
Health care insurance	$	$
Health care expenses (excluding insurance listed above)	$	$
Other insurance (describe)	$	$
Entertainment	$	$
Laundry and dry cleaning	$	$
Donations	$	$
Gifts	$	$
Union and other dues	$	$
Garnishment or income withholding order	$	$
Retirement deposits (including pensions, 401(k), IRA, etc.)	$	$
Other (describe)	$	$
Other (describe)	$	$
Total monthly expenses	$	$

I have estimated the amounts in paragraph 7.

Item estimated	Basis for estimation

8. Business Interests (attach proof of amounts listed)

I have no business interests. I have the following business interests.

Business name	Address & phone	Nature of business	Current value of the business	Percent owned
			$	_____% Petitioner _____% Respondent
			$	_____% Petitioner _____% Respondent

I have estimated the amounts in paragraph 8.

Item estimated	Basis for estimation

9. Financial Assets (attach proof of amounts listed)

I have no financial assets. I have the following financial assets.

Asset	Name & address of institution	Names on account	Current balance
Bank or credit union Account #: _______________ Date opened: _______________ Type: checking savings other			$
Bank or credit union Account #: _______________ Date opened: _______________ Type: checking savings other			$
Stocks, bonds, securities, money market account Account #: _______________ Date opened: _______________			$
Retirement account Account #: _______________ Date opened: _______________			$
Profit sharing plan Account #: _______________ Date opened: _______________			$
Annuity Account #: _______________ Date opened: _______________			$
Life insurance Account #: _______________ Date opened: _______________			$
Money owed to me Date of loan: _______________			$
Cash			$
Other (describe)			$
Other (describe)			$

I have estimated the amounts in paragraph 9.

Item estimated	Basis for estimation

10. Real Estate (attach proof of amounts listed)

I have no real estate. I have the following real estate.

Home
Address
Date acquired	Name(s) on title

Original cost	Current value
$	$
First mortgage or lien holder (name & address)	Amount owed / Monthly payments
	$ / $
Second mortgage or lien holder (name & address)	Amount owed / Monthly payments
	$ / $

Other real estate
Address
Date acquired	Name(s) on title

Original cost	Current value
$	$
First mortgage or lien holder (name & address)	Amount owed / Monthly payments
	$ / $
Second mortgage or lien holder (name & address)	Amount owed / Monthly payments
	$ / $

I have estimated the amounts in paragraph 10.

Item estimated	Basis for estimation

11. Personal Property (attach proof of amounts listed)

Such as vehicles, boats, trailers, major equipment, furniture, jewelry, and collectibles.

I have no personal property. I have the following personal property.

Property description (if automobile, include year, make, and model)	Debt owed to (name and address)	Names on title (if applicable)	Amount owed	Minimum monthly payments
			$	$
			$	$
			$	$
			$	$
			$	$

I have estimated the amounts in paragraph 11.

Item estimated	Basis for estimation

12. Debts Owed (attach proof of amounts listed)

Do not include amounts you owe on property reported in the Real Estate or Personal Property sections.

I do not owe any debts. I owe the following debts.

Type of debt (such as credit card, cash loan, or installment payment)	Debt owed to (name, address and phone number)	Names on debt	Amount owed	Minimum monthly payments
			$	$
			$	$
			$	$
			$	$
			$	$
			$	$

I have estimated the amounts in paragraph 12.

Item estimated	Basis for estimation

Warning: If you do not fully disclose all assets and income in this document and provide attachments you could be subject to sanctions under Utah Rule of Civil Procedure 37. Sanctions can include an award of non-disclosed assets to the other party, attorney's fees or other sanctions.

I declare under criminal penalty under the law of Utah that everything stated in this document is true.

Signed at (city, and state or country)

Date

Signature

Printed Name