Superior Court of Washington

County of

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.

                                                (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).)

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                                                                                                                           $                       

                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                                                                                  $                       

                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                                                      $                   

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).