Financial Declaration

IN AND FOR THE STATE OF WASHINGTON COUNTY OF CLARK ) ) Petitioner, ) ) vs. ) ) ) Respondent. ) ________________________________) No. FINANCIAL DECLARATION (FNDCLR) 1. GENERAL INFORMATION Name: Address (omit, if confidential): Telephone #: Employer Name: Employer Address: Spouse's Name: Spouse's Employer Name: Spouse's Employer Address: 1.2 PERSONS (including children) WHOM YOU FINANCIALLY SUPPORT Name Age Relationship Address 1.3 ALL OTHER ADULTS LIVING IN THE HOME Name Age Relationship Contribution to Household Expenses FINANCIAL DECLARATION Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 2. INCOME AND ASSETS Gross Monthly Income (personal): Other Income: Cash: Savings: Current spouse or partner living in residence: Home (cash value less amount owing): Auto (cash value less amount owing): Furniture (approximate value): Notes, Mortgages, Trusts, Deeds: Stocks, Bonds (approximate value): Other Assets and Property: Any Indebtedness Owed to You: 3. MONTHLY EXPENSES Rent or Mortgage: Food: Utilities: Transportation: Installment payments (per month): Medical & Dental: Insurance: Other: Total Monthly Expenses: 3.1 DEBTS Name of Creditor: Amount Owed: Under the penalty of perjury I declare that I have examined this document and the preceding information is true and accurate to the best of my knowledge and ability. _____________________________ Signature FINANCIAL DECLARATION Page 2 __________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com