Sworn Financial Statement

Your Employment

1. Monthly Income

(Convert annual, bi-monthly, and weekly amounts to monthly amounts.)

Gross Monthly Income Social Security Benefits (SSA)
Unemployment & Veterans’ Benefits Disability, Workers’ Compensation
Pension & Retirement Benefits Interest & Dividends
Public Assistance (TANF)
Other -
Total Monthly Income
Miscellaneous Income
Royalties, Trusts, and Other Investments Contributions from Others
Dependent Children’s monthly gross income. Source of Income: All other sources, i.e. personal injury settlement, non-reported income, etc.
Rental Net Income Expense Accounts
Child Support from Others
Other -
Spousal/Partner Support from Others
Other -
Total Monthly Miscellaneous Income
Total Income

2. Monthly Deductions

Mandatory and Voluntary

Mandatory Deductions Cost Per Month Cost Per Month
Federal Income Tax State/Local Income Tax
PERA/Civil Service Social Security Tax
Medicare Tax
Other -
Total Mandatory Deduction
Mandatory Deductions Cost Per Month Cost Per Month
Life and Disability Insurance Stocks/Bonds
Health, Dental, Vision Insurance Premium Retirement & Deferred Compensation
Total number of people covered on Plan
Child Care (deducted from salary)
Other -
Flex Benefit Cafeteria Plan
Other -
Total Voluntary Deduction
Total Monthly Deduction

3. Monthly Expenses

A. Housing

Cost Per Month Cost Per Month
1st Mortgage 2nd Mortgage
Insurance (Home/Rental) & Property Taxes (not included in mortgage payment) Condo/Homeowner’s/Maintenance Fees
Rent
Other -
Total Housing

B. Utilities and Miscellaneous Housing Services

Cost Per Month Cost Per Month
Gas & Electricity Water, Sewer, Trash Removal
Telephone (local, long distance, cellular & pager) Property Care (Lawn, snow removal, cleaning, security system, etc.)
Internet Provider, Cable & Satellite TV
Other -
Total Utilities and Miscellaneous Housing Services

C. Food & Supplies

Cost Per Month Cost Per Month
Groceries & Supplies Dining Out
Total Food & Supplies

D. Health Care Costs (Co-pays, Premiums, etc.)

Cost Per Month Cost Per Month
Doctor & Vision Care Dentist and Orthodontist
Medicine & RX Drugs Therapist
Premiums (if not paid by employer)
Other -
Total Health Care

E. Transportation & Recreation Vehicles

(Motorcycles, Motor Homes, Boats, ATV, Snowmobiles, etc.)

Cost Per Month Cost Per Month
Primary Vehicle Payment Other Vehicle Payments
Fuel, Parking, and Maintenance Insurance & Registration/Tax Payments (yearly amount(s) ÷12)
Bus & Commuter Fees
Other -
Total Transportation

F. Children’s Expenses and Activities

Cost Per Month Cost Per Month
Clothing & Shoes Child Care
Extraordinary Expenses i.e. Special Needs, etc. Misc. Expenses, i.e. Tutor, Books, Activities, Fees, Lunch, etc.
Tuition
Other -
Total Children’s Expenses and Activities

G. Education for you - Please identify status:

Cost Per Month Cost Per Month
Tuition, Books, Supplies, Fees, etc.
Other -
Total Education

H. Maintenance (Spousal/Partner Support) & Child Support (that you pay)

Cost Per Month Cost Per Month
Maintenance Child Support
Total Maintenance and Child Support

I. Miscellaneous (Please list on-going expenses not covered in the sections above)

Cost Per Month Cost Per Month
Recreation/Entertainment Personal Care (Hair, Nail, Clothing, etc.)
Legal/Accounting Fees Subscriptions (Newspapers, Magazines, etc.)
Charity/Worship Movie & Video Rentals
Vacation/Travel/Hobbies Investments (Not part of payroll deductions)
Membership/Clubs Home Furnishings
Pets/Pet Care Sports Events/Participation
Other -
Other -
Total Miscellanous
Total Monthly Expenses (Totals from A – I)

4. Debts (unsecured)

Name of Creditor Account Number (last 4-digits only) P C/R J Date of Balance Balance Minimum Monthly Payment Required Reason for Which Debt was Incurred
Unsecured Debt Balance

SWORN FINANCIAL STATEMENT SUMMARY
(INCOME/EXPENSES)

Total Income
Total Monthly Deductions
Total Monthly Net Income
Total Monthly Expenses
Total Minimum Monthly Payment Required - Debts Unsecured
Total Monthly Expenses and Payments
Net Excess or Shortfall (Monthly Net Income less Monthly Expenses and Payments)

5. Assets

A. Real Estate (Address or Property Description and Name of Creditor/ Lender)
P C/R J Estimated Value as of Today
Value = what you could sell it for in its current condition. 		Amount Owed Net Value/Equity
(Value minus amount owed)
Total
B. Motor Vehicles & Recreation Vehicles Including Motorcycles, ATV’s, Boats, etc.) (Year, Make, Model) (Name of Creditor/Lender)
P C/R J Estimated Value as of Today
Value = what you could sell it for in its current condition. 		Amount Owed Net Value/Equity
(Value minus amount owed)
Total
C. Cash on Hand, Bank, Checking, Savings, or Health Accounts (Name of Bank or Financial Institution)
P C/R J Type of Account Account # (last 4-digits only) Balance as of Today
Total
D. Life Insurance (Name of Company/Beneficiary)
P C/R J Type of Policy Face Amount of Policy Cash Value today
Total
E. Furniture, Household Goods, and Other Personal Property, i.e. Jewelry, Antiques, Collectibles, Artwork, Power Tools, etc. Identify Items and report in total.
P C/R J Current Possession Held by Estimated Value as of Today
Value = what you could sell it for in its current condition.
P C/R J
Total
F. Stocks, Bonds, Mutual Funds, Securities & Investment Accounts
Total
G. Pension, Profit Sharing, or Retirement Funds
Total
H. Miscellaneous Assets
Total
Notes
I. Separate Property
Total
Total Value/Balance of All Assets (A – I)