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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

Extracted Text for Proper Search

_________________________ _________________________                    
_________________________  _________________________ 
_________________________  _________________________ 	
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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