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South Dakota Financial Affidavit Form

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South Dakota Financial Affidavit Form Page 2
South Dakota Financial Affidavit Form
Page 2 of 4
Form UJS-304
Rev. 02/2014
STATE OF SOUTH DAKOTA )
IN CIRCUIT COURT
:SS
COUNTY OF______________ )
___________ JUDICIAL CIRCUIT
_______________________,
DIV _____
Plaintiff,
vs.
FINANCIAL AFFIDAVIT
_______________________,
Defendant.
I, ________________________________, hereby swear under oath and under penalty of law that the following is true.
(Name of party filling out this affidavit)
(1) My mailing address is ______________________________________________________
(2) My telephone number is ( ) _______________________________________
(3) I am (check one) _____ EMPLOYED _____ UNEMPLOYED _____ SELF-EMPLOYED
(4) (If employed) my monthly gross pay is: $_____________________________.
(5) Monthly gain or profit from a business or profession (self-employment): $________________________.
(6) Pension, retirement, disability, veterans, social security or insurance payments received regularly:
$___________________ per ______________.
(7) Interest, dividends, rentals, royalties or other gains: $______________________ per _________________.
(8) Gain from sale, trade or conversion of capital assets: $________________________.
(9) Unemployment insurance and workers compensation benefits: $___________________ per _______________.
(10) Benefit in lieu of compensation including but not limited to military pay allowances: ______________________ per
_______________________________.
(11) Other income (including spousal support received). Explain:__________________________________________.
$___________________ per ______________.
TOTAL GROSS MONTHLY INCOME (Add 4-11): $_______________________
(12) Income tax based on one withholding allowance for a single taxpayer (not actual number of dependents):
$_______________.
(13) Social Security and Medicare taxes withheld from wages or salary: $___________________.
(15) Contributions to an IRS qualified retirement plan not exceeding 10% of gross income:$ __________________.
(16) Unreimbursed employee business expenses (Attach IRS form 2106): $________________________________.
(17) Payments made on other support orders OTHER THAN FOR CHILDREN IN THIS PROCEEDING: $___________.
(Attach court order and evidence of payments).
(18) Payments made for spousal support: $_____________________.
TOTAL DEDUCTIONS (Add 12-18): $___________________
NET MONTHLY INCOME (SUBTRACT TOTAL DEDUCTIONS FROM GROSS MONTHLY
INCOME): $__________________
(19) My total gross income before deductions for the previous year was $______________________.
(20) My total gross income before deductions for two years ago was $______________________.
(21) Including myself, I have the following number of dependents: _____________________.
(22) Do you have health insurance available for dependents through your employer _________________
South Dakota Financial Affidavit Form