Fillable Superior Court of Washington County of (Washington)

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Superior Court of Washington County of (Washington)

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Financial Declaration (FNDCLR) - Page 1 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
Superior Court of Washington
County of
In re:
Petitioner,
and
Respondent.
No.
Financial Declaration
Petitioner
Respondent
(FNDCLR)
Name: Date of Birth:
I. Summary of Basic Information
Declarant’s Total Monthly Net Income (from § 3.3 below) $
Declarant’s Total Monthly Household Expenses (from § 5.9 below) $
Declarant’s Total Monthly Debt Expenses (from § 5.11 below) $
Declarant’s Total Monthly Expenses (from § 5.12 below) $
Estimate of the other party’s gross monthly income (from § 3.1f below) $
unknown
II. Personal Information
2.1 Occupation:
2.2 The highest year of education completed:
2.3 Are you presently employed? Yes No
a. If yes: (1) Where do you work. Employer's name and address must be listed on the
Confidential Information Form.
Financial Declaration (FNDCLR) - Page 2 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
(2) When did you start work there (month/year)? _______________________
b. If no: (1) When did you last work (month/year)? _______________________
(2) What were your gross monthly earnings? $
(3) Why are you presently unemployed?
III. Income Information
If child support is at issue, complete the Washington State Child Support Worksheet(s), skip Paragraphs 3.1 and 3.2.
If maintenance, fees, costs or debts are at issue and child support is Not an issue this entire section should be
completed. (Estimate of other party’s income information is optional.)
3.1 Gross Monthly Income
If you are paid on a weekly basis, multiply your weekly gross pay by 4.3 to determine your monthly wages
and salaries. If you are paid every two weeks, multiply your gross pay by 2.15. If you are paid twice
monthly, multiply your gross pay by 2. If you are paid once a month, list that amount below.
Name Name
a. Wages and Salaries $ $
b. Interest and Dividend Income $ $
c. Business Income $ $
d. Spousal Maintenance Received
From ____________________________ $ $
e. Other Income $ $
f. Total Gross Monthly Income (add lines 3.1a through 3.1e) $ $
g. Actual Gross Income (Year-to-date) $ $
3.2 Monthly Deductions From Gross Income
a. Income Taxes $ $
b. FICA/Self-employment Taxes $ $
c. State Industrial Insurance Deductions $ $
d. Mandatory Union/Professional Dues $ $
e. Pension Plan Payments $ $
f. Spousal Maintenance Paid $ $
g. Normal Business Expenses $ $
h. Total Deductions from Gross Income $ $
(add lines 3.2a through 3.2g)
3.3 Monthly Net Income (Line 3.1f minus line 3.2h or $ $
line 3 from the Child Support Worksheet(s).)
Financial Declaration (FNDCLR) - Page 3 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
3.4 Miscellaneous Income
a. Child support received from other relationships $ $
b. Other miscellaneous income (list source and amounts)
__________________________________________ $ $
__________________________________________ $ $
__________________________________________ $ $
__________________________________________ $ $
c. Total Miscellaneous Income (add lines 3.4a through 3.4b) $ $
3.5 Income of Other Adults in Household $ $
3.6 If the income of either party is disputed, state monthly income you believe is correct and explain below:
IV. Available Assets
4.1 Cash on hand $
4.2 On deposit in banks $
4.3 Stocks and bonds, cash value of life insurance $
4.4 Other liquid assets: $
V. Monthly Expense Information
Monthly expenses for myself and ____________ dependents are: (Expenses should be calculated for the future,
after separation, based on the anticipated residential schedule for the children.)
5.1 Housing
Rent, 1st mortgage or contract payments $
Installment payments for other mortgages or encumbrances $
Taxes & insurance (if not in monthly payment) $
Total Housing $
5.2 Utilities
Heat (gas & oil) $
Electricity $
Financial Declaration (FNDCLR) - Page 4 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
Water, sewer, garbage $
Telephone $
Cable $
Other $
Total Utilities $
5.3 Food and Supplies
Food for ___________ persons $
Supplies (paper, tobacco, pets) $
Meals eaten out $
Other $
Total Food Supplies $
5.4 Children
Day Care/Babysitting $
Clothing $
Tuition (if any) $
Other child-related expenses $
Total Expenses Children $
5.5 Transportation
Vehicle payments or leases $
Vehicle insurance & license $
Vehicle gas, oil, ordinary maintenance $
Parking $
Other transportation expenses $
Total Transportation $
5.6 Health Care (Omit if fully covered)
Insurance $
Uninsured dental, orthodontic, medical, eye care expenses $
Other uninsured health expenses $
Total Health Care $
5.7 Personal Expenses (Not including children)
Clothing $
Hair care/personal care expenses $
Financial Declaration (FNDCLR) - Page 5 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
Clubs and recreation $
Education $
Books, newspapers, magazines, photos $
Gifts $
Other $
Total Personal Expenses $
5.8 Miscellaneous Expenses
Life insurance (if not deducted from income) $
Other _____________________________________________ $
Other _____________________________________________ $
Total Miscellaneous Expenses $
5.9 Total Household Expenses (The total of Paragraphs 5.1 through 5.8) $
5.10 Installment Debts Included in Paragraphs 5.1 Through 5.8
Description Month of
Creditor of Debt Balance Last Payment
5.11 Other Debts and Monthly Expenses not Included in Paragraphs 5.1
Through 5.8
Description Month of Amount of
Creditor of Debt Balance Last Payment Monthly
Payment
$
$
$
$
$
$
$
Total Monthly Payments for Other Debts and Monthly Expenses $
Financial Declaration (FNDCLR) - Page 6 of 6
WPF DRPSCU 01.1550 (6/2006) - RCW 26.18.220(1)
5.12 Total Expenses (Add Paragraphs 5.9 and 5.11) $
VI. Attorney Fees
6.1 Amount paid for attorney fees and costs to date: $
6.2 The source of this money was:
6.3 Fees and costs incurred to date: $
6.4 Arrangements for attorney fees and costs are:
6.5 Other:
I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Signed at (City)________________________, (State) _________ on (date) ______________________.
Signature of Declarant Print or Type Name
The following financial records are being provided to the other party and filed separately with the court.
Financial records pertaining to myself:
Individual Partnership or Corporate Income Tax returns for the years _____________.
______________________________________________including all W-2s and schedules;
Pay stubs for the dates of ______________________________________________________
__________________________________________________________________________.
Other:
.
Do not attach these financial records to the financial declaration. These financial
records should be served on the other party and filed with the court separately
using the sealed financial source documents cover sheet (WPF DRPSCU
09.0220). If filed separately using the cover sheet, the records will be sealed to
protect your privacy (although they will be available to all parties in the case,
their attorneys, court personnel and certain state agencies and boards.) See GR
22 (C)(2).
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Superior Court of Washington County of (Washington)

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Completed 15 December 2020

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