Request edit access
Sworn Financial Statement
Please provide all information below. If something does not apply, please write NA. Incomplete forms will be rejected by the court. There will be a hourly fee to revise any forms due to rejection from lack of information.
Sign in to Google to save your progress. Learn more
Name
Date
MM
/
DD
/
YYYY
Address
City, State, and Zip Code
Email
Phone
How long have you lived in CO *
Date of Birth
Last four of your SSN
Are you seeking Spousal Support? *
Are you seeking Child Support *
Has their ben a change in circumstances that requires a modification to support? If so, what is that change? (Put NA for none) *
Child(ren) Name and Date Of Birth *
Child(ren) Address *
What county was your case filed in?
Case number (Put NA if no case number)
On what date was the original case finalized? (Put NA if no case)
Name of Petitioner in this case
Name of Respondent in this case *
Sworn Financial Statement
Check one
Court address
In re:
I
I am employed ___ # hours per week
I am paid
My pay is based on 

Monthly salary of
Hourly rate of 
or 
Other (explain)
Date employment began
MM
/
DD
/
YYYY
My occupation is
Name of employer
Address of employer
If unemployed, what date did you last work
MM
/
DD
/
YYYY
I am unemployed due to 
If other, explain
The household consists of 

# of adults
# of minor child(ren)
I believe the monthly gross income of the other party is...
Annual gross income for petitioner:
last tax year:
Annual gross income for co-petitioner/respondent: 
last tax year:
Monthly income (convert annual, bi-monthly, and weekly amounts to monthly amounts) 
Gross income (before taxes and deductions) from salary and wages, including commissions, bonuses, overtime, self-employment, business income, other jobs, and monthly reimbursed expenses.
Unemployment and veterans' benefits
Pension and retirement benefits
Public assistance (TANF)
Social Security benefits (SSA)
SSDI (disability insurance - entitlement program)
Social Security benefits (SSA)
SSI (supplemental income - need based) 
Disability, workers' compensation
Interest and dividends
Other (and what is it)
Total monthly income
Miscellaneous monthly income
Royalties, trusts, and other investments
Dependent children's monthly gross income and source of income
Rental net income
Child support from others
Spousal/partner support from others
Contributions from others
All other sources (i.e. personal injury settlement, non-reported income, etc.)
Expense accounts
Other (include what it is)
Total monthly miscellaneous income
Total income (monthly and monthly miscellaneous)
Monthly deductions (Mandatory and voluntary)
Mandatory deductions cost per month
Federal income tax
PERA/Civil service
Medicare tax
State/local income tax
Social security tax
Other (What is it) 
Total mandatory deductions
Voluntary deductions
Life and disability insurance
Health, dental, vision insurance premium (and number of people covered on plan) 
Childcare (deducted from salary)
Flex benefit cafeteria plan
Stock/bonds
Retirement and deferred compensation
Other (and what is it)
Total voluntary deductions
Total monthly deductions (mandatory and voluntary)
Monthly expenses 

***note - list regular monthly expenses below that you pay on an on-going basis and that are not identified in the deductions above)***
A. Housing cost per month
1st mortgage
Insurance (home/rental) and property taxes (not included in mortgage payment)
Rent
2nd mortgage
Condo/homeowner's/maintenance fees
Other (and what it is)
Total housing cost per month
B. Utilities and miscellaneous housing services cost per month
Gas and electricity
Telephone (local, long distance, cellular, and pager)
Internet provider, cable, and satellite TV
Water, sewer, trash removal
Property care (lawn, snow removal, cleaning, security system, etc.) 
Other (and what is it)
Total utilities and miscellaneous housing services cost per month
C. Food and supplies cost per month
Groceries and supplies
Dining out
Total food and supplies cost per month
D. Health care costs (co-pays, premiums, etc.) cost per month
Doctor and vision care
Medicine and RX drugs
Premiums (if not paid by employer)
Dentist and orthodontist
Therapist
Other (and what is it)
Total health care costs per month
E. Transportation and recreation vehicles (motorcycles, motor homes, boats, ATV, snowmobiles, etc.) cost per month
Primary vehicle payment
Fuel, parking, and maintenance
Bus and commuter fees
Other vehicle payments
Insurance and registration / tax payments (yearly/12) 
Other (and what is it)
Total transportation and recreation vehicles costs per month
F. Children's expenses and activities cost per month
Clothing and shoes
Extraordinary expenses (i.e. special needs)
Tuition
Child care
Misc. expenses (i.e. tutor, books, activities, fees, lunch, etc.)
Other (and what is it)
Total children's expenses and activities
G. Education for you cost per month
Identify status
Tuition, books, supplies, fees, etc.
Other (and what is it)
Total education for you cost per month
H. Maintenance (spousal/partner support) and child support (that you pay) cost per month
Maintenance for this family
Maintenance for other family
Child support for this family
Child support for other family
Total maintenance and child support cost per month
I. Miscellaneous (please list on-going expenses not covered in the sections above) cost per month
Recreation / entertainment
Legal / accounting fees
Vacation, travel, hobbies
Charity / worship
Memberships / clubs
Pets / pet care
Personal care (hair, nail, clothing, etc.)
Subscriptions (Newpapers, magazines, etc.)
Move and video rentals
Investments (not part of payroll deductions)
Home furnishings
Sports events / participation
Other (and what is it)
Total miscellaneous cost per month
Total monthly expenses (Totals from A through I)
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 the 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/respondent, and J=joint
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Name of creditor:
Account number (last 4):
P, C/R, or J:
Date of Balance:
Balance:
MINIMUM monthly payment required:
Reason for which debt was incurred:
Total minimum monthly payments for unsecured debts
Sworn Financial Statement Summary (Income/Expenses)
A. Total income
B. Total monthly deductions
Total monthly net income (A minus B)
C. Total monthly expenses
D. Total minimum monthly payment required - debts unsecure)
Total monthly expenses and payments (C plus D)
Net excess or short fall (monthly net income less monthly expenses and payments) +/- 
Assets
You MUST disclose all assets correctly. By indicating "none", you are stating affirmatively that you or the other part do not have assets in that category. Please attach additional copies of the remaining pages to identify your assets if necessary.

If the parties are married or partners in a civil union, check under the heading J/Joint ass assets acquired during the marriage / civil union but not by gift or inheritance/ Under the headings of P/Petitioner or C/R/Co-petitioner/respondent, 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 heading of P/Petitioner or C/R/Co-petitioner/respondent.
A. Real estate
None
Address or property description:
Name of creditor/lender:
P, C/R, or J:
Estimated Value of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed)
Address or property description:
Name of creditor/lender:
P, C/R, or J:
Estimated Value of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed)
Address or property description:
Name of creditor/lender:
P, C/R, or J:
Estimated Value of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed)
Total estimated value as of today
Total amount owed
Total net value/equity
B. Motor vehicles and recreation vehicles including motorcycles, ATV, boat, etc.)
None
Year, make, model:
Name of creditor/lender:
P, C/R, or J:
Estimated value as of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed):
Year, make, model:
Name of creditor/lender:
P, C/R, or J:
Estimated value as of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed):
Year, make, model:
Name of creditor/lender:
P, C/R, or J:
Estimated value as of today (what you could sell it for in its current condition):
Amount owed:
Net value/equity (value minus amount owed):
Total estimated value as of today
Total amount owed
Total net value/equity
C. Cash on hand, bank, checking, savings, or health accounts
None
Name of bank/financial institution:
P, C/R, or J:
Type of account:
Account # (last 4 digits):
Balance as of today:
Name of bank/financial institution:
P, C/R, or J:
Type of account:
Account # (last 4 digits):
Balance as of today:
Name of bank/financial institution:
P, C/R, or J:
Type of account:
Account # (last 4 digits):
Balance as of today:
Total balance as of today
D. Life insurance
None
Name of company/beneficiary:
P, C/R, or J:
Type of policy:
Face amount of policy:
Cash value today:
Name of company/beneficiary:
P, C/R, or J:
Type of policy:
Face amount of policy:
Cash value today:
Name of company/beneficiary:
P, C/R, or J:
Type of policy:
Face amount of policy:
Cash value today:
Total face amount of policy
Total cash value today
E. Furniture, household goods, and other personal property (i.e. jewelry, antiques, collectibles, artwork, power tools, etc.) LIST ONLY THINGS YOU ARE FIGHTING OVER
None
Identify items and report in total:
P, C/R, or J:
Current possession held by P, C/R/ or J:
Estimated value as of today (what you could sell it for in its current condition):
Identify items and report in total:
P, C/R, or J:
Current possession held by P, C/R/ or J:
Estimated value as of today (what you could sell it for in its current condition):
Identify items and report in total:
P, C/R, or J:
Current possession held by P, C/R/ or J:
Estimated value as of today (what you could sell it for in its current condition):
Identify items and report in total:
P, C/R, or J:
Current possession held by P, C/R/ or J:
Estimated value as of today (what you could sell it for in its current condition):
Total estimated value as of today
F. Stocks, bonds, mutual funds, securities, and investment accounts
Stocks, bonds, mutual funds, securities, and investment accounts
Total
G. Pension, profit sharing, or retirement funds
Pension, profit sharing, or retirement funds
Total
H. Miscellaneous assets
None
Miscellaneous assets - if you own any of the assets identified below, please check the appropriate box and attach JDF 1111-SS to report the value
If other, what is it
Total
I. Separate property
Separate property
List separate property below and its value
Total
Total Value / balance of all assets (A through I)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms