Fillable FINANCIAL STATEMENT The Financial Statement is used to (Virginia Department of Motor Vehicles)

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FINANCIAL STATEMENT The Financial Statement is used to (Virginia Department of Motor Vehicles)

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Commonwealth of Virginia
Department of Social Services
Division of Child Support Enforcement
I058-02-2018 Page 1 of 5 Barcode
FINANCIAL STATEMENT
DATE:
Division Case Number:
The Financial Statement is used to determine the proper amount of child support for your case. It is important to return
this document along with proof of income and expenses within the specified time frame in order to receive proper
credit on the support obligation worksheet.
S
ECTION A: HOUSEHOLD/SUPPORT ORDER INFORMATION
CP/NCP FIRST NAME MIDDLE NAME LAST NAME
Social Security Number:
Date of Birth:
Mailing Address:
City, State, Zip:
Residential Address:
(if different)
Phone
Home:
Work:
Cell:
Email address:
Your nearest living relative:
Relationship:
Relative’s Address:
City, State, Zip Code:
Phone:
Names of dependents in this case:
Dependents living with you for whom you are the biological or adoptive parent:
Child’s Name
Birth Date
Relationship
Other persons presently supported by you under any court or administrative order:
Name
Address
Birth Date
Relationship
Order Date/Type
Payee
Ordered Amount
Total Amount Paid
(Court or
Administrative)
(Person you pay)
($ amt and pay
frequency)
(Over last 6 months)
To receive credit for the above payments, you must provide proof such as pay stubs, receipts from the custodial parent
on the case, or other documents that verify payments.
I058-02-2018 Page 2 of 5 Barcode
If
you pay or receive spousal support/alimony, provide the following information:
Order Date
Issuing Court
$
Amount/Frequency
Paid to/Received
from
SECTION B: INCOME / EMPLOYMENT
Are you self-employed?
Yes No
NOTE: If you are self-employed, you must submit your most current tax return including all Schedules, as well as
a record of all self-employment tax you have paid this calendar year. Self-employed individuals may be entitled
to deductions from their gross monthly income that can only be determined if you provide this information.
Employer:
Employment Date:
Employer’s Address:
City, State, Zip Code:
Employer Phone:
Occupation:
Hourly Rate:
Pay Frequency (check one):
Weekly Bi-weekly Semi-monthly (twice/month) Monthly
Do you receive overtime pay? Yes
No
Gross pay per period:
(amount paid before deductions including overtime/shift
differential pay if applicable)
Do you have a 2
nd
job? Yes No
If yes, provide secondary employer information:
Employer:
Employment Date:
Employer’s Address:
City, State, Zip Code:
Employer Phone:
Occupation:
Hourly Rate:
Pay Frequency (check one):
Weekly Bi-weekly Semi-monthly (twice/month) Monthly
Do you receive overtime pay? Yes
No
Gross pay per period:
(amount paid before deductions including overtime/shift
differential pay if applicable)
Important: Attach copies of your 3 most recent pay stubs or a written statement from your employer(s)
verifying your average gross monthly income.
Do you receive income from any other source? Yes
No
Monthly amount:
Income is defined as salaries, wages, commissions, royalties, bonuses, dividends, severance pay, pensions,
interest, trust income, annuities, capital gains, social security benefits, workers’ compensation benefits,
unemployment insurance benefits, disability insurance benefits, veteran’s benefits, spousal support, rental
income, gifts, prizes or awards.
Current gross monthly income (total amount of income from all sources indicated
above):
Total income over last 12 months (total amount of all W-2’s):
I058-02-2018 Page 3 of 5 Barcode
Past employment and periods of unemployment: List all previous employers and periods of unemployment for
the last 12 months:
Name
Address
Gross
Monthly
Income
E
mployment
Dates
SECTION C: HEALTH INSURANCE
Please provide proof of insurance and insurance costs.
Is health insurance available at your place of employment? Yes No
Do you have health insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
Is vision insurance available at your place of employment? Yes No
Do you have vision insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
Is dental insurance available at your place of employment? Yes No
Do you dental health insurance? Yes
No
Are the children on this case included in the policy? Yes
No
Name and relationship of others covered in this policy:
Name
Relationship
Name of insurance
company:
Policy number:
I058-02-2018 Page 4 of 5 Barcode
If insurance is not available through your employer, is it available through other groups or organizations or your
union?
Yes No
If yes, what group?
P
lease provide the following information if you are providing insurance or if insurance coverage is offered through your
employer or another group or organization (the costs for each option must be provided to receive credit for the cost of
providing coverage):
Cost of health insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
Cost of vision insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
Cost of dental insurance:
Employee only
$
per
Employee plus 1
$
per
Employee plus family
$
per
SECTION D: DEPENDENT CARE EXPENSES
Please provide proof of dependent care expenses. A statement or multiple receipts from the child care provider must be
provided in order to receive credit.
List only child care information necessary due to your employment (for children on this case only):
Child Care Provider
Phone Number
Amount paid
Frequency
Does the Department of Social Services pay any portion of your child care expenses? Yes No
If yes, amount paid:
$
per
SECTION E: PROPERTY AND RESOURCES
Do you own in whole or part any of the following?
Real Estate (Land or Buildings):
Yes No
Fair Market
Price
Location
Amount
Owed
Mortgagee
Income
Producing
Profit per
Year
Yes No
Yes No
Yes No
Other assets:
Yes No
If yes, please explain:
Bank accounts:
Yes No
Name of bank or credit
union:
I058-02-2018 Page 5 of 5 Barcode
I hereby certify under penalty of perjury as set forth in Va. Code § 63.2-502 that I have given the statements in this
document and they are true and correct. I further agree to notify the Division of Child Support Enforcement of any
changes in my income or expenses.
Signature
Date
According to Va. Code § 63.2-1919, financial statements from noncustodial and custodial parents must be filed with the
Department of Social Services upon request as long as a debt to the Department exists or an authorization for the
Department to collect or enforce a support obligation exists. Failure to return this financial statement may adversely
affect your child support obligation and shall constitute a Class 4 misdemeanor.
To obtain additional case and/or payment information, visit our customer service portal at
https://mychildsupport.dss.virginia.gov/.
NOTICE: Section 7 of the Privacy Act (5 USC § 552a) and Section 466(a)(13) of the Social Security Act [42 USC§ 666(a)(13)] require all individuals subject to child
support orders to provide their social security numbers. These numbers will be kept in the case records and will only be used to locate individuals for purposes of
establishing paternity and establishing, modifying, and enforcing support obligations.
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Completed 23 February 2022

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