West Virginia Financial Disclosure Statement Form
Through the information gleaned from this form, the Court is able to identify the spouse who will pay for spousal support. Moreover, if the couple has minor children, the information in this form will also form the basis of the child support arrangement.Download
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_________________________ _________________________ _________________________ _________________________ _________________________ _________________________ IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA. In Re: The Marriage / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent Address Address Daytime phone Daytime phone FINANCIAL STATEMENT This form MUST be completed in ALL DIVORCE, CHILD SUPPORT, AND PATERNITY CASES. The Petitioner and the Respondent must each complete one of these forms. The completed form MUST be filed in the Circu it Clerk’s Office and served on the opposing party AT LEAST 5 DAYS BEFORE THE FIRST HEARING. If the Bureau For Child Support Enforcement is a party, the completed form mu st also be served on their local office. If your case involves minor children , or either party requests spousal support , you MUST file the following information WITH your completed Financial Statement. 1. A copy of your most recent wage or salary stub showing gross pay, deductions for taxes and other items, and net pay for a normal pay period, and for the year-to-date; 2. Copies of the your and your spouse’s complete income tax returns for the two years immediately preceding the date the petition was filed, together with copies of the f\ ederal Form W-2 for those years; and a copy of the Form W-2 for the most recent year for which that form is available, even if a tax return has not yet been filed for that year; 3. For self-employed persons and business owners, a copy of a current financial statement showing gross income, expenses, and net income; 4. Copies of any invoices or receipts showing the cost of any extraordinary medical expenses for the party or the children, of any child care expenses, and of any expenses n\ ecessitated by the special needs of the children. If the information you provide in this form, or file with this form changes after you file the form, you MUST immediately provide the new information. The information you provide on this form is ONLY for the use in the judi\ cial system, and is required by law and court rule to be kept CONFIDENTIAL. SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 1 of 9 Read each question carefully. Provide all requested information. Write or print clearly. After you have completed the form, you MUST sign the Verification on the last page before a Notary Public. Full Name: ____________________________________ Social Security No: _________________ Address: ___________________________________________________ P hone # : _____________ Any physical or mental disability: _____________________________________________________ Age: ____ Education: _____________________________________________________________\ _ Employer: __________________________________ Type of work: ________________________ Employment Address: ___________________________________________ Phone #: ______\ ______ Date Employed: ______________________ Gross pay per pay period: _____________________ Paid: ___ Weekly ___ Every two weeks ___ Twice a Month ___ Monthly Do you receive TANF benefits? ______ If “Yes,” list monthly amount: ___________________ YOUR INCOME : You MUST attach written documentation for all income. For wage earning employees who work fluctuating hours and/or overtime, provide wa ge history of at least six months, or length of most recent employment, whichever is less. Wage / salary history MUST be documented by W-2 forms, and/or year-to-date figures on the most recent pay stubs. For self-employed individuals, income MUST be verified by documents which show gross income and expenses. Income Source Monthly Amount 1. Salary 2. Wages 3. Commissions 4. Bonuses 5. Tips 6. Payments from a pension plan 7. Social Security, SSI 8. Other; explain SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 2 of 9 _________ _________ _________ _________ ____________ _________ ____________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ _________ PROPERTY List ALL property in which you, and / or your spouse have an interest. In the “Who owns?” column, put “M” for marital property; “H” if separate propert y of husband; “W” if separate property of wife. Property Description Market Value Amount Owed Who owns? Marital Home $_________ $_________ Other Real Estate $_________ $_________ Mobile Home $_________ $_________ Motor Vehicles $_________ $_________ $_________ $_________ $_________ $_________ Household Goods $_________ $_________ Checking Accts. $_________ $_________ Savings Accts. / CDs $_________ $________ Money Market Certificates $_________ $_________ Stocks $_________ $_________ Credit Union Accts. $_________ $_________ Profit Sharing Plans $_________ $_________ Trusts $_________ $_________ Stocks / Mutual Funds $_________ $_________ Bonds $_________ $_________ Pension Plans $_________ $_________ IRA / SEP Accts. $_________ $_________ Severance Pay; Unemployment $_________ $_________ Worker’s Comp. $_________ $_________ Whole life Insurance $_________ $_________ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 3 of 9 ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ Property Description Market Value Amount Owed Who owns? Annuities $_________ $_________ _________ Guns $_________ $_________ _________ Tools $_________ $_________ _________ Jewelry $_________ $_________ _________ Personal Property not located in Marital Home $_________ $_________ _________ Other*; __________________ $_________ $_________ _________ _________________________ $_________ $_________ _________ *Other includes, but is not limited to: coin collections; art; state and federal tax refunds; money owed to you or your spouse; business interests; money expected from a lawsuit or settlement; education benefits; patents; copyrights; royalties; conten ts of safe deposit boxes; and anything else of value. PROPERTY CONVEYED TO OTHERS List all real or personal property with a valu e of $500.00 or more that was sold, given away, or otherwise transferred by you and / or your spouse within the last 5 year\ s. Describe each such item; list market value when transferred; list type of transf er; provide name of the person to whom property was transferred; list amount received. DEBTS List all debts owed by you, and / or your spouse. In the “Whose debt?” column, put “M” for marital debt; “H” if separate debt of husband; “W” if separate debt of wife. Owed to Whom? Amount Owed For what? Secured by? Whose debt? 1____________________ $_________ ____ 2____________________ $_________ ____ 3____________________ $_________ ____ 4____________________ $_________ ____ 5____________________ $_________ ____ Total owed: $___________ Total of all monthly payments: $___________ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 4 of 9 ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ _____ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ _______ CHILDREN List the names; ages; birth dates; and social security numbers of all minor children involved in this case. Then, answer the list of questions about the children. Do your children receive social security benefits? ____ If “Yes,” list amount per month: $________ Do your children receive income or wages? ____ If “Yes,” list amount per month: $________ Do your children have any special needs that result in extraordinary exp\ enses that should be taken into account when the court sets the amount of child support? ____ If “Yes,” explain: Are child care expenses currently being paid so that the parent who take\ s care of the children can work or seek work? ____ If “Yes,” how much per month? $_________ You MUST attach receipts. Are you the parent of minor children OTHER than the minor children involved in this case? _____ Do you provide support for any disabled adult children? _____ If “Yes,” list these children’s names, ages, the nature of their disability, and the amount of support you provide each month. You must attach receipts or other documentation for the support you provide. HEALTH INSURANCE Is health insurance available to you through your employment? ____ If you answered “No,” you MUST provide written verification from your employer that health insurance is not available to you . If you have health insurance from ANY source, you MUST complete the following table . Insurance company name Address Policy number SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 5 of 9 ________________________________________________________________________\ __________ ________________________________________________________________________\ ________ ________________________________________________________________________\ ________ ________________________________________________________________________\ ________ Group number Any other ID numbers Persons covered Restrictions Amount of children’s portion of premium Deductibles Do you have recurring, out of pocket health expenses for yourself or your children that are not covered by insurance? If “Yes,” you MUST attach documents that verify these expenses . CHILD SUPPORT PAYMENTS Do you currently pay court ordered child support payments for any children OTHER than the children involved in this case? ____ If “Yes,” you MUST attach a copy of the Support Order, and records showing your payment history; and you must list the following information for each child: full name; birth date; social security number; monthly payment for that child. SPOUSAL SUPPORT If you are requesting spousal support, you MUST complete the following list of monthly expenses. These are the amounts you now pay if you are living separate from you spouse. If you have not yet separated, list the amounts you estimate you will have to pay when you do separate. MONTHLY EXPENSES Credit card payments; other payments on unsecured debts: $ ________ Car payments: $________ Rent or mortgage: $_______ Electric: $_______ Gas: $_______ Water / Sewer: $_______ Trash: $_______ Telephone: $_______ TV Cable: $_______ Food: $_______ Clothing: $_______ Gasoline: $_______ Car repairs: $_______ Car insurance: $_______ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 6 of 9 ________________________________________________________________________\ __________ ________________________________________________________________________\ ________ ________________________________________________________________________\ ________ ________________________________________________________________________\ ________ Health insurance: $_______ Other insurance: $_______ Explain: ___________________________ Home repair and maintenance: $_______ Child care: $_______ Entertainment & recreation: $_______ Medical & health not covered by insurance: $_______ Explain: _____________________________ Other: $_______ Explain: ___________________________________________________________ TOTAL MONTHLY EXPENSES: $___________ IF EITHER YOU OR YOUR SPOUSE IS REQUESTING SPOUSAL SUPPORT, YOU MUST COMPLETE THE REST OF THIS FORM. Wife's Education Graduate from high school? ____ If “Yes,” what year? ____ If “No,” receive a GED? ____ If GED, year? _______ Graduate from technical or trade school? ____ If “Yes,” list type of training or degree and year received. _______________________________. Graduate from college? ____ If “Yes,” list degree and year received. _________________________ Receive a post-graduate degree? ____ If “Yes,” list degree and year received. __________________ Wife's Employment History List last four jobs. List employer; position held; dates employment began and ended; monthly salary. Husband's Education Graduate from high school? ____ If “Yes,” what year? ____ If “No,” receive a GED? ____ If GED, year? _______ Graduate from technical or trade school? ____ If “Yes,” list type of training or degree and year received. _______________________________. Graduate from college? ____ If “Yes,” list degree and year received. _________________________ Receive a post-graduate degree? ____ If “Yes,” list degree and year received. __________________ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 7 of 9 ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ __________ ________________________________________________________________________\ ________ ________________________________________________________________________\ ________ Husband's Employment History List last four jobs. List employer; position held; dates employment began and ended; monthly salary. Wife’s Health Wife’s age: _____ Wife's physical health is: ____ Excellent ____ Good ____ Poor If “Poor,” explain: __________ ________________________________________________________________________\ _______. Wife's mental and emotional health is: ____ Excellent ____ Good ____ Poor If “Poor,” explain: ________________________________________________________________________\ _______. Husband’s Health Husband’s age: _____ Husband's physical health is: ____ Excellent ____ Good ____ Poor If “Poor,” explain: _______ ________________________________________________________________________\ _______. Husband's mental and emotional health is: ____ Excellent ____ Good ____ Poor If “Poor,” explain: _______________________________________________________________\ ___________ ________________________________________________________________________\ ________. Obtaining Additional Education or Training Would additional training and / or education help the party seeking spous\ al support to increase earning ability within a reasonable time? ____ If “Yes,” e xplain what type of training or education; the estimated yearly cost of such training or education; and the length of time it would take to complete this training or education: ____________________________________________\ _______________ SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 8 of 9 ________________________________________________________________________\ _________ ________________________________________________________________________\ _________ ___________________________ _________________________ ___________________________ ____________ Additional Information Explain why you think spousal support should be awarded, or denied: ____\ ____________________ VERIFICATION I, ____________________________, after making an oath of affirmation to tell the truth, say that the facts I have stated in this Financial St atement are true of my personal knowledge; and if I provided information from other persons, I believe that information to be true. I understand that deliberately failing to provide complete disclosure, and knowingly providing incorrect information constitute the crime of false swearing. Signature This Verification was sworn to or affirmed before me on the ____ day of __________________, ______. Notary Public / Other Official My commission expires:____________________. CERTIFICATE of SERVICE State of West Virginia County of _______________________________ I, ____________________________, the person completing this Financial Statement, mailed copies the Financial Statement and all attached documents, by first class mail, postage paid, to: _____________________________, at the address of _______________________\ ______________ _____________________________, at the address of _______________________\ ______________ on the ____ day of __________________, _____. Signature Date SCA-FC-106 (2/02) FINANCIAL STATEMENT PAGE 9 of 9
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