JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 1 of 7

District Court Denver Juvenile Court

___________________ County, Colorado Court Address:

In re:

The Marriage of:

The Civil Union of:

Parental Responsibilities concerning:______________________________________________________

Petitioner:

and

Co-Petitioner/Respondent: COURT USE ONLY

Attorney or Party Without Attorney (Name and Address):

Phone Number:FAX Number:

E-mail:Atty. Reg. #:

Case Number:

Division Courtroom

SWORN FINANCIAL STATEMENT I, ___________________________________________________ (full name) am am not currently employed.

I am employed ____ hours per week. I am paid weekly bi-weekly twice a month monthly.

My pay is based on a Monthly Salary Hourly rate of $__________ Other: _________________________

Date employment began _______________________________.

My occupation is: ____________________________ Name of employer: _______________________________

Address of employer: _________________________________________________________________________

If unemployed, what date did you last work? _______________________

I am unemployed due to disability involuntary layoff at work other: ________________________________

This household consists of _____ adult(s), and ______ minor child(ren).

I believe the monthly gross income of the other party is $___________.

Annual gross income (last tax year 20__) for Petitioner $ _________, Co-Petitioner/Respondent $ __________

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

Gross Monthly Income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, self-employment, business income, other jobs, and monthly reimbursed expenses.

$

Social Security Benefits (SSA)

SSDI (Disability insurance – entitlementprogram)

SSI (supplemental income – need based)

$

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

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 2 of 7

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 Deductions Voluntary Deductions Cost Per

Month Cost Per Month

Life and Disability Insurance Stocks/Bonds Health, Dental, Vision Insurance Premium

Total number of people covered on Plan

Retirement & Deferred Compensation

Child Care (deducted from salary) Other - ____________________

Flex Benefit Cafeteria Plan Other - ____________________

Total Voluntary Deductions

Total Monthly Deductions

3. Monthly ExpensesNote: List regular monthly expenses below that you pay on an on-going basis and that are not identifiedin the deductions above.

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 - ________________

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 - ____________________

Services Utilities and Miscellaneous Housing

C. Food & Supplies

Cost Per Month

Cost Per Month

Groceries & Supplies Dining Out

& Supplies

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

Total

Total

Food Total

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 3 of 7

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 - ________________

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 - ________________

G. Education for you - Please identify status: Full-time student Part-time student

Cost Per Month

Cost Per Month

Tuition, Books, Supplies, Fees, etc. Other - ________________

Education

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

Cost Per Month

Cost Per Month

Maintenance Child Support

This family This family

Other family Other family

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 - ________________

Other - ________________ Other - ________________

Other - ________________ Other - ________________

Other - ________________ Other - ________________

Total

Total Children’s Expenses Activities and

Total

Child and Maintenance Total

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 4 of 7

Total Miscellaneous $

Total Monthly Expenses (Totals from A – I)

$

4. Debts (unsecured)

List unsecured debts such as credit cards, store charge accounts, loans from family members, back taxes owed to the I.R.S., etc. Do not list debts that are liens against your property, such as mortgages and car loans, because that payment is already listed as an expense above, and the total of the debt is shown elsewhere as a deduction from value where that asset is listed, such as under Real Estate or Motor Vehicles.

For name on account, "P" = Petitioner, "C/R” = Co-Petitioner or Respondent, "J" = Joint.

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 $

$

→Total Minimum Monthly Payment

SWORN FINANCIAL STATEMENT SUMMARY (INCOME/EXPENSES)

Total Income (from Page 1) $ _____________ A Total Monthly Deductions (from Page 2) $ _____________ B

Total Monthly Net Income (A minus B) $ _____________ Total Monthly Expenses (from Page 3) $ _____________ C Total Minimum Monthly Payment Required - Debts Unsecured (from Page 4) $ _____________ D

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 5 of 7

Total Monthly Expenses and Payments (C plus D) $ _____________

Net Excess or Shortfall (Monthly Net Income less Monthly Expenses and Payments) (+/-) $ ______________

5. Assets

You MUST disclose all assets correctly. By indicating “None”, you are stating affirmatively that you or the other party, do not have assets in that category. Please attach additional copies of pages 5 & 6 to identify your assets, if necessary.

If the parties are married or partners in a civil union, check under the heading Joint (J) all assets acquired during the marriage/civil union but not by gift or inheritance. Under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R), check assets owned before this marriage/civil union and assets acquired by gift or inheritance.

If the parties were NEVER married to each other or are using this form to modify child support, list all of each party’s assets under the headings of Petitioner (P) or Co-Petitioner/Respondent (C/R).

"P" = Petitioner, "C/R” = Co-Petitioner or Respondent, "J" = Joint.

A. Real Estate (Address or Property Description and Name of Creditor/ Lender)

None

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)

None

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)

None

P C/R J Type of Account

Account # (last 4-digits

only)

Balance as of Today

$

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 6 of 7

Total $

D. Life Insurance (Name of Company/Beneficiary)

None

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.

None

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

None If owned please attach JDF 1111-SS.

Total

$

G. Pension, Profit Sharing, or Retirement Funds

None If owned please attach JDF 1111-SS.

Total

$

H. Miscellaneous Assets

None If you own any of the assets identified below, please check the appropriate box and attach JDF 1111-SS to report the value.

Business Interests Stock Options Money/Loans owed to you IRS Refunds due to you

Country Club &

Other Memberships Livestock, Crops,

Farm Equipment Pending lawsuit or claim

by you Accrued Paid Leave (sick,

vacation, personal) Oil and Gas Rights Vacation Club Points Safety Deposit Box/Vault Trust Beneficiary Frequent Flyer Miles Education Accounts Health Savings Accounts Mineral and Water Rights Other - __________ Other - ___________ Other - _____________ Other - _____________ Total

$

I. Separate Property

None If owned please attach JDF 1111-SS to identify the property and to report the value.

Total

$

Total Value/Balance of All Assets (A – I) $

By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.

By checking this box, I am acknowledging that I have made a change to the original content of this form.

JDF 1111SC R1/18 SWORN FINANCIAL STATEMENT – FORM 35.2 Page 7 of 7

I understand that if the information I have provided changes or needs to be updated before a final decree or order is issued by the Court, that I have a duty to provide the correct or updated information. I understand that if I have omitted or misstated any material information, intentionally or not, the Court will have the power to enter orders to address those matters, including the power to punish me for any statements made with the intent to defraud or mislead the Court or the other party.

VERIFICATION

I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country _____________________________________ ____________________________________ (printed name of Petitioner or Co-Petitioner/Respondent) Signature of Petitioner or Co-Petitioner/Respondent

CERTIFICATE OF SERVICE

I certify that on ________________________ (date) a true and accurate copy of the SWORN FINANCIAL STATEMENT was served on the other party by:

Hand Delivery, E-filed, Faxed to this number: ___________________, or

By placing it in the United States mail, postage pre-paid, and addressed to the following:

To: _______________________________________

_______________________________________

_______________________________________ ______________________________________ Your signature

County: The Marriage of: OffThe Civil Union of: OffParental Responsibilities concerning: OffCity: State: Zip: Phone: Email: Case Number: Division: Courtroom: Name: √ JDF 1111: 1-1: Off1-2: Off1-3: Off1-4: Off1-5: Off1-6: Off1-7: Off1-8: Off1-9: Off1-1A: Off1-11: Off1-12: Off1-13: Off1-14: Off1-15: Off3-1: Off3-2: Off3-3: Off3-4: Off3-5: Off3-6: Off5-A1: Off5A-A1: Off5A-A2: Off5A-A3: Off5A-B1: Off5A-B2: Off5A-B3: Off5A-C1: Off5A-C2: Off5A-C3: Off5B-1: Off5B-A1: Off5B-A2: Off5B-A3: Off5B-B1: Off5B-B2: Off5B-B3: Off5B-C1: Off5B-C2: Off5B-C3: Off5B-D1: Off5B-D2: Off5B-D3: Off5C-1: Off5C-A1: Off5C-A2: Off5C-A3: Off5C-B1: Off5C-B2: Off5C-B3: Off5C-C1: Off5C-C2: Off5C-C3: Off5C-D1: Off5C-D2: Off5C-D3: Off5D-A1: Off5D-A2: Off5D-A3: Off5D-B1: Off5D-B2: Off5D-B3: Off5D-C1: Off5D-C2: Off5D-C3: Off6E-1: Off6E-A1: Off6E-A2: Off6E-A3: Off6E-A4: Off6E-A5: Off6E-A6: Off6E-B1: Off6E-B2: Off6E-B3: Off6E-B4: Off6E-B5: Off6E-B6: Off6E-C1: Off6E-C2: Off6E-C3: Off6E-C4: Off6E-C5: Off6E-C6: Off6E-D1: Off6E-D2: Off6E-D3: Off6E-D4: Off6E-D5: Off6E-D6: Off6E-E1: Off6E-E2: Off6E-E3: Off6E-E4: Off6E-E5: Off6E-E6: Off6F-1: Off6F-2: Off6G-1: Off6G-2: Off6H-1: Off6H-A1: Off6H-A2: Off6H-A3: Off6H-A4: Off6H-B1: Off6H-B2: Off6H-B3: Off6H-B4: Off6H-C1: Off6H-C2: Off6H-C3: Off6H-C4: Off6H-D1: Off6H-D2: Off6H-D3: Off6H-D4: Off6H-E1: Off6H-E2: Off6H-E3: Off6H-E4: Off6I-1: Off6I-2: Off7-1: Yes

JDF 1111: 1 I am employed: 1-A: 1-B: 1-C: 1-D: 1-E: 1-F - Employer Address: 1-G: 1-H: 1-I: 1-J: 1-K: 1-L: 1-M: 1-N: 1-1: 1-2: 1-3: 1-4: 1-5: 1-6: 1-7: 1-O: 1-8: 1-9: 01-10: 1-P: 1-11: 1-12: 1-13: 1-14: 1-15: 1-16: 1-17: 1-Q: 1-18: 1-R: 1-19: 1-20: 01-21: 02-A: 2-B: 2-C: 2-D: 2-E: 2 Other_8: 2-F: 2-G: 02-H: 2-I: 2-J: 2-K: 2-L: 2-M: 2-N: 2 Other_10: 2-O: 2 Other_12: 2-P: 2-Q: 02-R: 02-3A-1: 2-3A-2: 2-3A-4: 2-3A-5: 2-3A-3: 2-3A-A: 2-3A-6: 2-3A-7: 02-3B-1: 2-3B-2: 2-3B-3: 2-3B-4: 2-3B-5: 2-3B-A: 2-3B-5A: 2-3B-6: 02-3C-1: 2-3C-2: 2-3C-3: 02-3D-1: 2-3D-2: 2-3D-3: 2-3D-4: 2-3D-5: 2-3D-A: 2-3D-6: 2-3D-7: 03-3E-1: 3-3E-2: 3-3E-3: 3-3E-4: 3-3E-5: 3-3E-A: 3-3E-6: 3-3E-7: 03-3F-1: 3-3F-2: 3-3F-4: 3-3F-5: 3-3F-3: 3-3F-A: 3-3F-6: 3-3F-7: 03-3G-1: 3-3G-A: 3-3G-2: 3-3G-3: 03-3H-1: 3-3H-2: 3-3H-3: 3-3H-4: 3-3H-5: 3-3H-6: 3-3H-7: 03-3I-1: 3-3I-2: 3-3I-3: 3-3I-4: 3-3I-5: 3-3I-6: 3-3I-A: 3-3I-7: 3-3I-B: 3-3I-8: 3-3I-C: 3-3I-9: 3-3I-D: 3-3I-10: 3-3I-11: 3-3I-12: 3-3I-13: 3-3I-14: 3-3I-15: 3-3I-16: 3-3I-E: 3-3I-17: 3-3I-F: 3-3I-18: 3-3I-G: 3-3I-19: 3-3I-H: 3-3I-20: 3-3I-21: 03: 04-B2: 04-B1: -14-A: 04-B: 04-C: 04-D1: 04-D: 04-E: 04-F: 04-G: 05A-1: 5A-A: 5A-B: 5A-B1: 05A-C: 05A-2: 5A-D: 5A-E: 5A-F: 05A-3: 5A-E1: 05A-G: 5A-H: 5A-I: 05A-H1: 05A-J: 05A-K: 05A-L: 05A-K1: 05B-A1: 5B-A2: 5B-A3: 5B-A4: 05B-A3X: 05B-B1: 5B-B2: 5B-B3: 5B-B4: 05B-B3X: 05B-C1: 5B-C2: 5B-C3: 5B-C4: 05B-C3X: 05B-D1: 5B-D2: 5B-D3: 5B-D4: 05B-D3X: 05B-E1: 05B-E2: 05B-E3: 05B-E2X: 05C-A1: 5C-A2: 5C-A3: 5C-A4: 5C-B1: 5C-B2: 5C-B3: 5C-B4: 5C-C1: 5C-C2: 5C-C3: 5C-C4: 5C-D1: 5C-D2: 5C-D3: 5C-D4: 5C-E1: 05D-1: Off5D-A1: 5D-A2: 5D-A3: 5D-A4: 5D-B1: 5D-B2: 5D-B3: 5D-B4: 5D-C1: 5D-C2: 5D-C3: 5D-C4: 5D-D1: 05D-D2: 06E-A1: 6E-A2: 6E-B1: 6E-B2: 6E-C1: 6E-C2: 6E-D1: 6E-D2: 6E-E1: 6E-E2: 6E-F1: 06F-3: 6G-3: 6H-E1: 6H-E2: 6H-E3: 6H-E4: 6H-1: 6I-1: 6-1: 07A: 7B: 7C: 7D:

Name of CreditorRow1: Account Number last 4 digits onlyRow1: Check Box4: 0: 0: Off1: Off2: Off

1: 1: Off0: Off2: Off

2: 0: Off1: Off2: Off

3: 0: Off1: Off2: Off

4: 0: Off1: Off2: Off

5: 0: Off1: Off2: Off

6: 0: Off1: Off2: Off

7: 0: Off1: Off2: Off

8: 0: Off1: Off2: Off

9: 0: Off1: Off2: Off

10: 0: Off1: Off2: Off

11: 0: Off1: Off2: Off

12: 0: Off1: Off2: Off

13: 0: Off1: Off2: Off

14: 0: Off1: Off2: Off

Date of BalanceRow1: Text15: Text151: Reason for Which Debt was Incurred: Name of CreditorRow2: Account Number last 4 digits onlyRow2: Row1_2: Date of BalanceRow2: Row1: Reason for Which Debt was IncurredRow2: Name of CreditorRow3: Account Number last 4 digits onlyRow3: Date of BalanceRow3: Row2: Row2_2: Reason for Which Debt was IncurredRow3: Name of CreditorRow4: Account Number last 4 digits onlyRow4: Date of BalanceRow4: Row3: Row3_2: Reason for Which Debt was IncurredRow4: Name of CreditorRow5: Account Number last 4 digits onlyRow5: Date of BalanceRow5: Row4: Row4_2: Reason for Which Debt was IncurredRow5: Name of CreditorRow6: Account Number last 4 digits onlyRow6: Date of BalanceRow6: Row5: Row5_2: Reason for Which Debt was IncurredRow6: Name of CreditorRow7: Account Number last 4 digits onlyRow7: Date of BalanceRow7: Row6: Row6_2: Reason for Which Debt was IncurredRow7: Name of CreditorRow8: Account Number last 4 digits onlyRow8: Date of BalanceRow8: Row7: Row7_2: Reason for Which Debt was IncurredRow8: Name of CreditorRow9: Account Number last 4 digits onlyRow9: Date of BalanceRow9: Row8: Row8_2: Reason for Which Debt was IncurredRow9: Name of CreditorRow10: Account Number last 4 digits onlyRow10: Date of BalanceRow10: Row9: Row9_2: Reason for Which Debt was IncurredRow10: Name of CreditorRow11: Account Number last 4 digits onlyRow11: Date of BalanceRow11: Row10: Row10_2: Reason for Which Debt was IncurredRow11: Name of CreditorRow12: Account Number last 4 digits onlyRow12: Date of BalanceRow12: Row11: Row11_2: Reason for Which Debt was IncurredRow12: Name of CreditorRow13: Account Number last 4 digits onlyRow13: Date of BalanceRow13: Row12: Row12_2: Reason for Which Debt was IncurredRow13: Name of CreditorRow14: Account Number last 4 digits onlyRow14: Date of BalanceRow14: Row13: Row13_2: Reason for Which Debt was IncurredRow14: Name of CreditorRow15: Account Number last 4 digits onlyRow15: Date of BalanceRow15: Row14: Row14_2: Reason for Which Debt was IncurredRow15: fill_143: 0fill_144: 0JDF 1111 Serv Date: Serve Fax Number: √ Serve Hand: Off√ Serve Efile: Off√ Serve Fax: Off√ Serve Mail: OffServe 1 Street Address: Serve 1 Name: Serve 1 City: Serve 1 State: Serve 1 Zip: √ District Court: Off√ Denver Juvenile Court: Offπ: ∆: Print: Clear: Street Address: Court Zip: Court State: Court City: Court Street Address: