Home > Legal > Legal > Affidavit Template > South Dakota Affidavit Form > South Dakota Financial Affidavit Template

South Dakota Financial Affidavit Form

At Speedy Template, You can download South Dakota Financial Affidavit Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.

South Dakota Financial Affidavit Form Page 3
South Dakota Financial Affidavit Form
Page 3 of 4
Form UJS-304
Rev. 02/2014
(23) If you provide medical or dental insurance for your child(ren), please complete the following:
Name of the Health and/or Dental Insurance Company ______________________________________
Total monthly cost for the employee only: $_____________________________
Total monthly cost for the employee and child(ren): $__________________________
Persons covered under the policy of insurance: ___________________________________________________.
(24) Do you incur child care costs as result of employment, job search or training or education necessary to obtain a job or
enhance earning potential ________________________
If so, please complete the following:
Name and address of child care provider: __________________________________________________________.
The name(s) of the child(ren) for whom child care is provided: __________________________________________.
How many hours per week is child care being provided _______________________________________________.
Cost of Child Care: Monthly: $_______________ Weekly: $____________ Hourly: $______________
List the costs, per month, of the child care expenses incurred for the past six months: __________________________
_______________________________________________________________________________________________
Do you receive any state assistance for child care _________________ If so, how much ____________________
Do you claim the Federal Child Care Tax Credit __________________
(25) Enter the amount of Social Security or Veteran’s Benefits provided to a child(ren) of the parties due to your
retirement, disability or other eligibility: $_____________________
Which parent receives the payment for the child ______________________
(26) The following amounts accurately represent my assets and liability:
1. ASSETS (things we own or are buying)
a. CASH (on hand or in banks) ………………………………………………………………….. $_____________
b. ACCOUNTS and NOTES RECEIVABLE (IOU’s and other money payable to me)……….. $_____________
c. INVESTMENTS(stocks, bonds, savings bond, CD’s, money market, stock options, etc.)….. $_____________
d. RETIREMENT ACCOUNT (account balance)………………………………………………. $_____________
e. REAL ESTATE (house, land, tribal lease land, rental property, etc.)………………………… $_____________
f. AUTOMOBILE(S) make, model, year:
________________________________________________________________________ $_____________
________________________________________________________________________ $_____________
g. RECREATIONAL VEHICLES (boats, campers, ATV’s, etc)………………………………. $_____________
h. HOUSEHOLD GOODS (furniture, appliances, TV, stereo, etc.)…………………………….. $_____________
i. SPORTING EQUIPMENT (hunting/fishing, camping, boating, etc.)……………………….. $_____________
j. JEWLREY…………………………………………………………………………………….. $_____________
k. TOOLS, SHOP EQUIPMENT……………………………………………………………….. $_____________
l. VALUE OF BUSINESS ……………………………………………………………………… $_____________
m. OTHER PERSONAL PROPERTY (tools, sports equipment, etc.)………………………..… $_____________
n. ANY OTHER ASSETS (anything else I could sell or borrow money on)………………….. $_____________
TOTAL VALUE OF ASSETS…………. $_____________
2. LIABILITIES (money that we owe)
a. Our regular monthly expenses are: (housing, utilities, food, insurance, etc.)……….….$_____________
b. DEBTS (vehicle loans, mortgages, credit cards, student loans, medical bills, personal loans, etc.):
I owe_______________________________ this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
I owe _______________________________this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
I owe _______________________________this amount……………….$_____________
I owe_______________________________ this amount……………….$_____________
I owe _______________________________this amount……………….$_____________
South Dakota Financial Affidavit Form