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					1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 II. PERSONAL INFORMATION Name: THOMAS EXAMPLE Date of Birth: 2/28/1975

IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In re the Marriage of : THOMAS EXAMPLE, Petitioner, JAIME LYNN TEMPLATE, Respondent. FINANCIAL DECLARATION OF THOMAS EXAMPLE [ x ] Petitioner [ ] Respondent

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 § 3.1g below)

$3683 $4437.5 $1211 $5648.5

[ ] [ x]
Unknown

FINANCIAL DECLARATION- 1

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3

2.1 2.2 2.3

Occupation: Realtor The highest year of education completed: High School Are you presently employed? a. If yes:

[ x ] Yes-

[ ] No

4 (1) Where do you work. Self Employed – Broker: Dave Template Examples,Inc. (2) When did you start work there? (month/year) 6 III. INCOME INFORMATION 7 If child support is at issue, complete the Washington State Child Support Worksheet(s), skip 8 Paragraphs 3.1 and 3.2. If maintenance, fees, costs or debts are at issue and child support is NOT an 9 issue this entire section should be completed. (Estimate of other party’s income information is 10 optional.) 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 f. g. a. b. c. d. e. Imputed Income Wages and Salaries Interest and Dividend Income Business Income Spousal Maintenance Received From Other Income Total Gross Monthly Income $3683 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. JAIME THOMAS $3683 October 2003 5

FINANCIAL DECLARATION- 2

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 b. 3.3 3.4 a. b. c. d. e. f. g. h. 3.2 h.

(add lines 3.1a through 3.1e) Actual Gross Income (Year-to-date) $44,197

MONTHLY DEDUCTIONS FROM GROSS INCOME. JAIME Income Taxes FICA/Self-employment Taxes State Industrial Insurance Deductions MANDATORY Union/Professional Dues Pension Plan Payments Spousal Maintenance Paid Normal Business Expenses Total Deductions from Gross Income (add lines 3.2a through 3.2g) $?? $?? THOMAS $50 500 $204 1044 $1798

MONTHLY NET INCOME. (Line 3.1f minus line 3.2h MISCELLANEOUS INCOME. Worksheet(s).) or line 3 from the Child Support a. Child support received from other relationships Name: Name: Other miscellaneous income
(list source and amounts)

$1885 JAIME THOMAS

-

FINANCIAL DECLARATION- 3

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 4.4 4.1 4.2 4.3 3.6 3.5 c.

Income of current spouse Name: Name: Total Miscellaneous Income
(add lines 3.4a through 3.4b)

-

$0

Income of Other Adults in Household Name: Name: TORI YOUNG Danniel Lewis $2000 $3600.-

If the income of either party is disputed, state monthly income you believe is correct and explain below: IV. AVAILABLE ASSETS Cash on hand On deposit in banks Stocks and bonds Cash value of life insurance Other liquid assets: 20.00 $300.00 $1200 $640 -

V. MONTHLY EXPENSE INFORMATION 16 Monthly expenses for myself and 17 separation, based on the anticipated residential schedule for the children.) 18 5.1 19 Rent, 1st mortgage or contract payments 20 Installment payments for other mortgages or 21 Encumbrances 22 Taxes & insurance (if not in monthly payment) 23 Total Housing 24 5.2 25 UTILITIES $1493 $1493 ($2986) HOUSING. 1 dependents are: (Expenses should be calculated for the future, after

FINANCIAL DECLARATION- 4

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 5.5 5.4 5.3

Heat (gas & oil) 1/2 Electricity 1/2 Water, sewer, garbage 1/2 Telephone Full Cable 1/2 Other (Internet): 1/2 Total Utilities FOOD AND SUPPLIES Food Supplies (paper, tobacco, pets) Meals eaten out Other: Total Food Supplies

$63 ($125) $63 ($125) $50 ($100) $19 $17.50 (35) $30 ($60) $ 252.5

$300 30 10 $340

CHILDREN. Day Care/Babysitting Clothing Tuition (if any) acting class, aikido Other child-related expenses books, toys, art supply, music Total Expenses Children TRANSPORTATION. Vehicle payments or leases Vehicle insurance & license Vehicle gas, oil, ordinary maintenance 433 $101 $250 $60 $385 275 50

FINANCIAL DECLARATION- 5

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 5.10 5.9 5.8 5.7 5.6

Parking Other transportation expenses Total Transportation HEALTH CARE. (Omit if fully covered) Insurance Uninsured dental, orthodontic, medical, eye care expenses (Out of pocket expenses for pallet expander, co-pays, medications) Other uninsured health expenses acupuncture herbs Total Health Care PERSONAL EXPENSES. (Not including children). Clothing Hair care/personal care expenses (Dry Cleaning) Clubs and recreation Education Books, newspapers, magazines, photos Gifts Other: Total Personal Expenses

10 0 $784

$275 $50 $325

$30 $60 $60 $30 $100 $50 $330

MISCELLANEOUS EXPENSES. Life insurance (if not deducted from income) Other: IRA Other: Child support Paymenst $84 64 $400 $528

Total Miscellaneous Expenses

TOTAL HOUSEHOLD EXPENSES (The total of Paragraphs 5.1 through 5.8)

$4437.5

INSTALLMENT DEBTS INCLUDED IN PARAGRAPHS 5.1 THROUGH 5.8.

FINANCIAL DECLARATION- 6

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Creditor/Description of Debt BANK OF AMERICA VISA 5.11

Balance $4698

Month of Last Payment $128

OTHER DEBTS AND MONTHLY EXPENSES NOT INCLUDED IN PARAGRAPHS 5.1 - 5.8 Month of Amount of Monthly Payment

Creditor/Description of Debt

Balance

Last Payment

Christine Templer

13000

Debt due in full March 09

(Persoanl Loan for household expenses Due in full March 09)
Total Monthly Payments for Other Debts and Monthly Expenses $1211.

TOTAL EXPENSES (Add Paragraphs 5.9 and 5.11)

$5648.5

VI. ATTORNEY FEES 6.1 6.2 6.3 6.4 Amount paid for attorney fees and costs to date: The source of this money was: Fees and costs incurred to date: Arrangements for attorney fees and costs are: $2000.00 LOAN n/a n/a -

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].

_____________________________ THOMAS EXAMPLE, Petitioner

The following financial records are being provided to the other party and filed separately with the court. Financial records pertaining to myself:

FINANCIAL DECLARATION- 7

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

[ ] 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).

19 20 21 22 23 24 25

FINANCIAL DECLARATION- 8

Stark Law Offices
155 108th Avenue NE, Suite 704 Bellevue, Washington 98004 www.StarkLawOffices.com (206) 347-0521


				
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