Colorado Sworn Financial Statement Form
Prior to the negotiation process for the Marital Settlement Agreement, the divorcing spouses must complete this form and exchange copies with each other.Download
Extracted Text for Proper Search
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 1 of 7
District Court Denver Juvenile Court
___________________ County, Colorado
Court Address:
In re:
The Marriage of:
Parental Responsibilities concerning:
______________________________________________________
Petitioner: and Co-Petitioner/Respondent :
COURT USE ONLY
Attorney or Party W ithout Attorney (Name and Address) :
Phone Number: __________ E-mail: ___________________________
FAX Number: ___________ Atty. Reg. #: __________________
Case Number:
Division ______ Courtroom _______
SWORN FINANCIAL STATEMENT
I, ___________________________________________________ (full name)
am am not currently employed.
I am employed ____ hours per week. I am paid
weekly bi -weekly twice a month monthly.
My pay is based on a
Monthly Salary Hourly rate of $_____ _____ Other: _______________________ __
Date employment began _______________________________.
My occupation is: ____________________________ Name of employer: _______________________________
Address of employer: _________________________________________________________________________
If unemployed, what date did you last w ork? _______________________
I am unemployed due to
disability involuntary layoff at work other: ________________________________
This household consist s of _____ adult(s), and ______ minor child(ren).
I believe the monthly gross income of the other party is $___________.
Annual gross income (last tax ye ar 20__) for Petitioner $ _________,
Co-P etitioner /Respondent $ __________
1. Monthly Income (Convert annual, bi -monthly, and weekly amounts to monthly amounts. )
Gross Monthly Income (before taxes and
deductions) from salary and wages, including
commissio ns, bonuses, overtime, self -
employment, business income, other jobs,
and monthly reimbursed expenses .
$ Social Security Benefits (SSA)
SSDI (Disability insurance – entitlement
program)
SSI (supplemental income – need based)
$
Unemployment & Veterans’ Benefits Disability, W orkers’ Compensation
Pension & Retirement Benefits Interest & Dividends
Public Assistance (TANF) Other - ___________________
Total Monthly Income $
Miscellaneous Income
Royalties, Trusts , and Other Investments $ Contributions from Other s $
Dependent Children’s monthly gross
income. Source of Income: __________
All other sources, i.e. personal injury
settlement, non -reported income, etc.
Rental Net Income Expense Accounts
Child Support from Others Other - ___________________
Spousal Support from Others Other - ___________________
Total Monthly Miscellaneous Income $
Total Income $
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 2 of 7
2. Monthly Deductions (Mandatory and Voluntary)
Mandatory Deductions Cost Per
Month
Cost Per
Month
Federal Income Tax $ State /Local Income Tax $
PERA/Civil Service Social Security Tax
Medicare Tax Other - ___________________
Total Mandatory Deductions $
Voluntary Deductions Cost Per
Month
Cost Per
Month
Life and Disability Insurance $ Stock s/Bonds $
Health, Dental, Vision Insurance Premium
Total number of people covered on Plan
Retirement & Defer red Compensation
Child Care (deducted from salary) Other - ____________________
Flex Benefit Cafeteria Plan Other - ____________________
Total Voluntary Deductions $
Total Monthly Deductions $
3. M onthly Expenses
Note:
List regular monthly expenses below that you pay on an on-going basis and that ar e not identified
in the deductions above.
A. Housing
Cost Per
Month
Cost Per
Month
1st Mortgage $ 2nd Mortgage $
Insurance (Home/Rental) & Property
Taxes (not included in mortgage payment)
Condo/Homeowner’s/Maintenance
Fees
Rent Other - _____ ___________
Total Housing $
B. Utilities and Miscellaneous Housing Services
Cost Per
Month
Cost Per
Month
Gas & Electricity $ Water , Sewer , Trash Removal $
Telephone (local, long distance, cellular &
pager)
Property Care (Lawn , snow removal,
cleaning , security system, etc.)
Internet Provider, Cable & Satellite TV Other - ____________________
Total Utilities and Miscellaneous Housing Services $
C. Food & Supplies
Cost Per
Month
Cost Per
Month
Groceries & Supplies $ Dining Out $
Total Food & Supplies $
D. Health Care Costs (Co-pays, Premiums, etc. )
Cost Per
Month
Cost Per
Month
Doctor & Vision Care $ Dentist and Orthodontist $
Medicine & RX Drugs Therapist
Premiums (if not paid by employ er) Other - ____________________
Total Health Care $
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 3 of 7
E . T ransportation & Recreation Vehicles (Motorcycles, Motor Homes, Boats, ATV, Snowmob iles, etc.)
Cost Per
Month
Cost Per
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
Cost Per
Month
Clothing & Shoes $ Child Care $
Extraordinary Expenses i. e. Special
Needs, etc.
Misc. Expenses , i.e. T utor, Books,
Activities, Fees , Lunch, etc.
Tuition Other - ________________
Total Children’s Expenses and Activities $
G. Education for you - Please identify status:
Full- time student Part -time student
Cost Per
Month
Cost Per
Month
Tuition , Books, Supplies, Fees, etc. Other - ________________
Total Education $
H . Maintenance & C hild Support (that you pay)
Cost Per
Month
Cost Per
Month
Spousal Maintenance Child Support
This family $ This family $
Other family Other family
Total Maintenance and Child Sup port $
I. Miscellaneous (Please list on-going expenses not covered in the sections above)
Cost Per
Month
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 Even ts/Participation
Other - ________________ Other - ________________
Other - ________________ Other - ________________
Other - ________________ Other - ________________
Other - ________________ Other - ________________
Total Miscellaneous $
Total Monthly Expenses (Total s from A – I)
$
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 4 of 7
4. Debts (unsecured)
List unsecured d ebts 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 th at 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.
Nam e of Creditor Account
Number
(last 4-
digits
only)
P C/R J Date of
Balance
Balance
Monthly
Payment
Required
Minimum Reason for
Which Debt
was Incurred
$ $
Unsecured Debt Balance
$
$
→Total
Minimum
Monthly
Payment
SWORN FINANCIAL STATEMENT SUMMARY
(INCOME/EXPENSES)
Total Income
(from Page 1) $ ________ _____ A
Total Monthly Deductions
(from Page 2) $ ________ _____ B
Total Monthly Net Income ( A minus B) $ _____________
Total Monthly Expenses
(from Page 3 ) $ ________ _____ C
Total Minimum Monthly Payment Required - Debts Unsecured
(from P age 4) $ _____________ D
Total Monthly Expenses and Payments (C plus D) $ _____________
Net Excess o r Shortfall (Monthly Net Income less Monthly Expenses and Payments) (+/-) $ ______________
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 5 of 7
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 cop ies of page s 5 & 6 to
identify your assets, if necessary.
If the parties are married , check under the heading J oi nt (J) all assets acquired during the marriage but not by
gift or inheritance. Under the headings of P etitioner (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 N ame of Creditor/ Lender)
None
P C/R J Estimated
Value as of
Today Value = what you could sell it for in its current condition.
Amount
Owed
Net
Value/Equity
(Value minus
amount
owed)
$ $ $
Total $ $ $
B. Motor Vehicles & Recreation
Vehicles Including Motorcycles, ATV’s,
Boats, etc.) (Year, Make, Model) (Name of
Creditor/Lender)
None
P C/R J Estimated
Value as of
Today Value = what you could sell it for in its current condition.
Amount
Owed
Net
Value/Equity
(Value minus
amount
owed)
Total $ $ $
C. Cash on Hand, Bank, Checking,
Savings, or Health Accounts (Name of
Bank or Financial Institution)
None
P C/R J Type of
Account
Account #
(last 4-digits
only)
Balance as
of Today
$
Total $
D. Life Insurance
(Name of Company/Beneficiary)
None
P C/R J Type of
Policy
Face Amount
of Policy
Cash Value
today
$ $
Total $ $
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 6 of 7
E. Furniture, Household Goods, and
Other Personal Property, i.e. Jewelry,
Antiques, Collectibles, Artwork, Power
Tools, etc. Identify Items and report in
total.
None
P C/R J Current Possession Held by Estimated
Value as of
Today Value = what you could sell it for in its current condition.
P C/R J
$
Total
$
F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts
None If owned please attach JDF 1111- SS.
Total
$
G. Pension, Profit Sharing, or Retirement Funds
None If owned please attach JDF 1111- SS.
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 Stock Options Money/Loans owed to you IRS Refunds due to you
Country Club &
Other Memberships
Livestock, Crops,
Farm Equipment
Pending lawsuit or claim
by you
Accrued Paid Leave (sick,
vacation, personal)
Oil and Gas Rights Va cation Club Points Safety Deposit Box/Vault Trust Beneficiary
Frequent Flyer Miles Education Accounts Health Savings Accounts Mineral and W ater Rights
Other - __________ Other - ___________ Other - _____________ Other - _____________
Total
$
I. 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) $
JDF 1111 R4/10 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 7 of 7
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: ___________________
________________________________________
Notary Public/Deputy Clerk
CERTIFICATE OF SERVICE
To be completed if the Sworn Financial Statement is not being filed with
J DF 1104 - Certificate of Compliance with Mandatory Financial Disclosures
I certify that on ________________________ (date) a true and accurate copy of the SWORN FINANCIAL
STATEMENT was served on the other party by:
Hand Delivery, E -filed, Faxed to this number: ___________________, or
By placing it in the United States mail, postage pre- paid, and addressed to the following:
To: _______________________________________
_______________________________________
_______________________________________ ______________________________________
Your signature
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