STATE OF SOUTH CAROLINA	)	IN THE FAMILY COURT OF THE
)	JUDICIAL CIRCUIT
COUNTY OF	)
)
)	FINANCIAL DECLARATION
Plaintiff,	)	OF
vs.	)
)
Defendant.	)	Docket No.

HUSBAND/FATHER	WIFE/MOTHER
Address	Address
Age	Age
Occupation	Occupation
Employer	Employer
Employer Address	Employer Address

Gross Monthly Income	Husband/Father	Wife/Mother
Principal Earnings from Employment
Overtime, Tips, Commission, Bonuses
Pensions, Retirement, and Annuities income
Additional Employment income
Social Security Benefits (SSA) and VA Benefits
Disability and Worker’s Compensation Benefits
Unemployment and AFDC
Spousal or Child Support (from other marriage/relationship)
Dividends, Interest, Trust Income, and Capital Gains
Rental Income and Business Profits
Other (Specify):
TOTAL GROSS MONTHLY INCOME

Payroll Deductions from Monthly Income	Husband/Father	Wife/Mother
Federal Income Tax
State Income Tax
Social Security and Medicare Tax (FICA)
Self-Employment Tax
Health and Dental Insurance (Adult)
Health and Dental Insurance (Child)
Union Dues
Voluntary Retirement Contribution (401(k), 457, IRA)
Mandatory Retirement Contribution
Savings Plan
Other (Specify):
TOTAL MONTHLY DEDUCTIONS
NET MONTHLY INCOME

Estimate monthly expenses: (Specify which party is the custodial parent and list name and relationship of all members of household whose expenses are included.

MONTHLY EXPENSES	Husband/Father	Wife/Mother
Residential Rent Payment
Note or Mortgage Payment on Residence(s)
Food and Household Supplies
Utilities, Water, and Garbage Collection
Telephone and Cellular Phone
Medical, Dental and Disability Insurance Premiums (not deducted from paycheck)
Life Insurance Premiums (not deducted from paycheck)
Child Support (from other relationship)
Work Related Day Care
Spousal Support (from prior marriage)
Auto Payment
Auto Insurance, taxes, gasoline, and maintenance

SUBTOTAL:

Real Property Tax on Residence(s)
Maintenance for household
Adult Clothing
Children’s Clothing
Cable Television, Satellite, and Internet/Online Services
Laundry and Dry Cleaning
Medical and Dental Expenses (not paid by insurance)
Prescriptions, Glasses, and Contacts (not paid by insurance)
Children’s incidental expenses
School lunches, supplies, field trips, and fees
Entertainment
Adult Incidental expenses
All Installment payments
Other (Specify):

SUBTOTAL:

TOTAL MONTHLY EXPENSES

Installment Loan Payments Section

Creditor	For	Monthly Payment	Balance	Owed by

Other Debts and Obligations not payable in monthly installments

Creditor	For	Date Payable	Balance	Owed by 16

Are you currently in Bankruptcy? YES NO

Are any obligations listed above, including mortgage and note payments, in arrears? YES NO

If yes, please list the obligations in arrears.

All Marital Property Known to Parties

Assets	Husband/Father	Wife/Mother	Joint
Cash and Money in Checking Account(s)
Money in Savings Account(s), Credit Union, Money Market, or Cert. of Dep.
Value of Voluntary Retirement Account(s)
Value of Pension Account
Value of Publicly Held Stocks, Bonds, Securities, Mutual Funds
Value of Privately Held Stocks and Other Business
Value of Real Estate – Net of Mortgage Balances
Value of All Other Property17
TOTAL ASSETS

Any Non Marital Property Known to Parties

Description of Asset	Title Owner	Date of Acquisition	Source of Funds to Acquirer	Estimate Present market Value

If total assets are less than $300,000.00, sign and have notarized.

If total assets are greater than $300,000.00, itemize assets by completing additional sections below and sign and have notarized.

Financial Accounts Section18

Owner	Name of Institution	Type of Account	Balance

Voluntary Retirement Accounts and Pension Accounts Section

Type of Account	Value

Publicly Held Stocks, Bonds, Securities, Mutual Funds Section (Non-Retirement)19

Name of Company	Number of Shares/Type of Account	Value

Real Estate Section20

Owner	Address	Value	Mortgage Balance	Mortgage Equity

Other Property Section17

Owner	Description of Asset	Value	Loan Balance	Equity

___________________________________________

Signature

Sworn to before me this of ,

2 .

_________________________________ (SEAL)

Notary Public for South Carolina

My commission expires: ____________

Custodial Parent (if applicable):

A recent paystub should be attached to the Financial Declaration. To compute Principal Earnings from Employment, first determine whether you are paid semi-monthly, biweekly, or weekly. If you are paid semi-monthly, multiply the gross amount of your pay check by two. If you are paid biweekly, multiply the gross amount of your pay check by 26 and then divide by 12. If you are paid weekly, multiply the amount of your paycheck by 52 and divide by twelve. Round to the nearest whole dollar.

To compute Overtime, Tips, Commission, and/or Bonuses, take an average of your monthly earnings from overtime, tips, commission, bonuses, etc. from the past three years or the length of employment if employed less than three years (including this year).

To compute State, Local, and Social Security Tax deductions, use the same formula used to compute principal earnings in endnote 1 above, or consult or have your attorney consult an accountant.

Net monthly Income is equal to Total Gross Monthly Income minus Total Monthly Deductions.

Do not include any expense in the Monthly Expenses section that has already been included in the Deductions from Gross Monthly Income on page one of the Declaration.

Food Expense is to include the cost of groceries, toiletries, cleaning supplies, and casual eating out.

Auto Expenses are to include gasoline, oil changes, tune-ups, tire replacement, maintenance, and related items.

Maintenance for Household is to include appliance and household repairs, landscaping, house cleaning, pest control, pool service, alarm service, and other related items.

Clothing Expense is to include shoes and clothing purchases, clothing repair and alterations, and related items.

Laundry Expense is to include the cost of laundry service, dry cleaning, and related items.

Children’s Incidental Expenses are to include allowance, summer camp, baby sitters, lessons, activities, participatory sports, and related items.

School Expense is to include tuition, supplies, field trips, dues, tutors, locker rentals, school lunches, and other related items.

Entertainment is to include movies, theater, vacations, sporting events, compact discs, digital video discs, and related items.

Adult Incidental Expenses are to include cosmetics, hair and nail care, books, magazines, newspapers, business dues, memberships, pets, charity, religious dues or tithes, gifts, bank charges, hobbies, and related items.

All Installment Loan Payments is the total amount itemized in Installment Loan Payments Section, which should include all loan payments not already listed as a monthly expense. Examples: home equity loan, credit cards, etc.

Indicate which spouse legally owes the payment (husband, wife, or joint).

Other property is to include automobiles (minus loan balance), boats (minus loan balance), furniture, furnishings, china, silver, jewelry, collectibles, and other personal property.

18. Itemize Financial Accounts such as checking, savings, credit union, money market, or certificate of deposit accounts in the

Financial Accounts Section.

19. Itemize Publicly Held Stocks, Bonds, Securities, Stock Options and Mutual Funds (excluding retirement accounts) in the

Publicly Held Stocks, Bonds, Securities, Mutual Funds Section.

20. Itemize each parcel of Real Estate in the Real Estate Section.

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SCCA 430 (12/2009)

STATE OF SOUTH CAROLINA

SCJD

2009-12-14

wclark

SCJD