Income and Expense Declaration Questionnaire
Name
First Name
Last Name
Employer
Employer address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Employer phone number
-
Area Code
Phone Number
Occupation
Date Job Started
-
Month
-
Day
Year
Date Picker Icon
If unemployed, date job ended
-
Month
-
Day
Year
Date Picker Icon
How many hours per week do you work?
How much do you get paid per month (gross, before taxes, FICA etc.)?
Your age
Have you completed high school?
If no, what was your highest grade completed?
Number of years of college completed?
Degrees obtained?
Number of years of graduate school completed?
Degrees obtained?
What professional or occupational licenses do you have?
What vocational training do you have?
What was the last tax year you filed in?
Your tax filing status is:
Single
Head of household
Married filing separately
Married filing jointly
If married filing jointly, with whom?
What state(s) do you file taxes in?
How many exemptions do you claim on your taxes?
What is your estimate of the other party's income?
What are you basing your estimate on (i.e. pay stubs, tax returns, observed expenses, other party's statements)?
What was your last month's gross (before taxes) salary or wages?
What is your average (last 12 months) month's gross (before taxes) salary or wages?
What was your last month's gross (before taxes) overtime?
What is your average (last 12 months) month's gross (before taxes) overtime?
What was your last month's commissions and bonuses?
What is your average (last 12 months) month's commissions and bonuses?
How much public assistance (TANF, SSI, GA/GR) did you receive last month?
How much public assistance (TANF, SSI, GA/GR) did you on average over the last 12 months?
How much monthly spousal support did you receive from this marriage last month?
How much monthly support did you receive from this marriage on average over the last 12 months?
How much monthly spousal support did you receive from a different marriage last month?
How much monthly support did you receive from a different marriage on average over the last 12 months?
How much monthly partner support did you receive from this domestic partnership last month?
How much monthly partner support did you receive from a different domestic partnership last month?
How much did you receive in pension/retirement fund payments last month?
How much do you receive on average monthly (12 months) in pension/retirement fund payments?
How much did you receive last month in social security retirement payments (not SSI)?
How much did you receive in an average month (12 months) in social security retirement payments (not SSI)?
How much did you receive last month in disability payments (social security (not SSI), state disability (SDI), and private insurance)?
How much did you receive in an average month (12 months) in disability payments (social security (not SSI), state disability (SDI), and private insurance)?
The disability payments you receive are from:
social security (not SSI)
state disability (SDI)
private insurance
How much did you receive last month in unemployment?
How much unemployment do you receive in an average month (12 months).
How much did you receive in workers compensation last month?
How much do you receive in an average month from worker's compensation (12 months)?
How much other compensation did you receive last month (military BAQ, royalty payments, etc.)?
How much other compensation do you receive in an average month (12 months) (military BAQ, royalty payments, etc.)?
How much income did you receive last months from dividends and interest?
How much income do you receive in an average month from dividends and interest?
How much income did you receive last months from rental property income (rent minus expenses)?
How much income do you receive in an average month (12 months) from rental property income (rent minus expenses)?
How much income did you receive last months from trust income?
How much income do you receive in an average month (12 months) from trust income)?
How much other investment income did you receive last month?
How much other investment income do you receive in an average month (12 months)?
If you are self-employed are you:
a sole proprietor
a business partner
other
If you are self employed and chose "other" as your business type, what type of business entity to you have (i.e. corporation, LLC, etc.)?
If you are self-employed, how many years have you been in business?
If you are self-employed, what is the name of your business?
If you are self-employed what is the type of business you are in?
Have you received any additional one-time money income such as lottery winnings, inheritance, etc. in the last 12 months?
If you received additional one-time money income in the last 12 months, please specify the source and amount?
If your financial situation has changed significantly in the last 12 months please specify how it has changed?
How much did you spend last month on required union dues?
How much did you spend last month on required retirement payments (not social security, FICA, 401(k), or IRA)?
How much did you spend last month in total on medical, hospital, dental, vision, and other health insurance premiums?
How much do you pay per month in child support for children from other relationships?
How much do you pay by court order in spousal support to a spouse from a different marriage?
How much do you pay by court order in partner support to a partner from a different domestic partnership?
How much do you pay in necessary job-related expenses not reimbursed by your employer?
If you have necessary job-related expenses not reimbursed by your employer, please explain the nature of the expenses?
How much do you own in total in checking accounts, savings, credit union, money marker, and other deposit accounts?
How much do you own in total of stocks, bonds, and other assets you could easily sell?
How much do you estimate is the fair market value of all other property that you own minus the debts that you owe?
For the fair market value of all other property that you own from the previous question, does that include:
real estate
personal property (non-real estate)
What are the names of the people who live with you?
What are the ages of the people who live with you?
How are the people who live with you related to you?
What are the gross monthly incomes of the people who live with you?
Do any of the people who live with you pay some of the household expenses?
In regard to your residence do you:
rent
pay mortgage
How much do you spend a month on your rent or mortgage?
If you pay a mortgage, how much of the monthly payment is principal?
If you pay a mortgage, how much of the monthly payment is interest?
How much do you pay each month in real estate property taxes?
How much do you pay each month in renter's or homeowner's insurance?
How much do you pay each month for repairs to your residence?
How much do you pay each month in health-care costs not covered by insurance?
How much do you pay each month for child care?
How much do you spend each month on groceries and household supplies?
How much do you spend each month on eating out?
How much do you spend each month on utilities such as gas, electric, water, and trash?
How much do you spend each month on telephone, cell phone, and email?
How much do you spend each month on laundry and cleaning?
How much do you spend each month on cloths?
How much do you spend each month on education?
How much do you spend each month on entertainment, gifts, and vacation?
How much do you spend each month on auto expenses and transportation such as insurance, gas, repairs, bus, etc.?
How much do you spend each month on insurance such as life and accident (do not include auto, home, or health insurance)?
How much do you spend each month on savings and investments?
How much do you spend each month on charitable contributions?
How much do you spend each month on other installment payments and debts not listed above?
What companies are the previously mentioned installment payments paid to?
What are the previously mentioned installment payments for?
What are the monthly amounts of the installment payments?
What are the balances of the installment payment accounts?
For each installment account, what is the date of the last payment?
How much have you paid your attorney to date?
What was the source of the money paid to your attorney?
How much do you still owe to your attorney?
How much is your attorney's hourly rate?
How many children do you have?
What percentage timeshare do you have with your children?
Do you have health insurance for your children available to you through your job?
I do
I do not
If so, what is the name of your health insurance company?
If so, what is the address of your health insurance company?
What is, or would be, the monthly health insurance cost of the children?
How much do you pay monthly for child care so that you can work or get job training?
How much do you pay per month in children's health care not covered by insurance?
How much do you pay per month in travel expenses for the children?
How much do you pay per month for children's educational or other special needs?
How much do you pay per month for special hardship extraordinary health care expenses not included in the previous question about children's health care costs not covered by insurance?
How much do you pay per month for special hardship major losses not covered by insurance such as fire, theft, and other insured loss?
How much do you pay in expenses for your minor children who are from other relationships and are living with you?
What are the names and ages of the minor children who are from other relationships and are living with you?
How much do you receive per month for minor children who are from other relationships and are living with you?
Is there any additional information you would like the court to know concerning support in your case?
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