Colorado Judicial Department Form JDF 1111SC (Form 35.2), Sworn Financial Statement Instructions

Enter the monthly payment amount you pay for your first mortgage.

Enter the monthly payment amount you pay for your second (junior) mortgage.

Enter the full name of the attorney or the party representing themself as it should appear on the court filing.

Enter the street address for the attorney or party, including apartment or suite number if applicable.

Enter the city of the mailing address for the attorney or party.

Enter the two-letter state abbreviation for the mailing address (e.g., CO).

Enter the postal ZIP code for the mailing address (5-digit ZIP or ZIP+4).

Enter the primary telephone number for the attorney or party, including area code.

Enter the email address where the court or other parties can contact the attorney or party.

Enter the fax number for the attorney or party, including area code, or leave blank if none.

Enter the attorney registration or bar number assigned by the state (if not an attorney, leave blank or enter N/A).

Check this box when the case concerns dissolution or matters related to a marriage (e.g., divorce, annulment, or marital settlement).

Check this box when the case concerns dissolution or matters related to a civil union (e.g., termination or related legal issues for a civil union).

Check this box when the case concerns parental responsibilities or custodial/parenting-time matters regarding a child or children.

Enter the full legal name of the petitioner (the person who filed the case) as it should appear on court documents.

Enter the full legal name of the co-petitioner or respondent (the other party in the case) as it should appear on court documents.

Check this box if you or the other party do not have any cash, bank, checking, savings, or health accounts to disclose.

Enter the date the Sworn Financial Statement was served on the other party.

Provide your signature for the Certificate of Service.

Enter the monthly amount deducted from the employee's salary for child care for this row.

Provide a short description or label for the 'Other' voluntary deduction listed in this row.

Enter the monthly cost associated with the 'Other' voluntary deduction described in this row.

Enter the monthly cost for clothing and shoes.

Enter the monthly cost for extraordinary expenses, such as special needs.

Enter the monthly cost for tuition.

Enter the monthly cost for child care.

Enter the monthly cost for miscellaneous expenses, including items like tutor, books, activities, fees, and lunch.

Enter the monthly cost for any other children's expenses not listed elsewhere.

Enter the total monthly cost for all children's expenses and activities.

Check this box when the case is being filed in the District Court jurisdiction.

Check this box when the case is being filed in the Denver Juvenile Court.

Enter the name of the Colorado county where this court is located.

Enter the court's full street address, including number, street name, and suite or room if applicable.

Enter the city in which the court is located.

Enter the state (abbreviation or full name) for the court's location.

Enter the postal ZIP code for the court's address.

Enter the court-assigned case number for this matter exactly as it appears on court documents.

Enter the division number or identifier assigned by the court for this case.

Enter the courtroom number or identifier where the case will be heard.

Check this box if, as the declarant, you are currently employed (i.e., the statement 'I am' applies to you).

Check this box if, as the declarant, you are not currently employed (i.e., the statement 'I am not currently employed' applies to you).

Enter the monthly cost for tuition, books, supplies, and fees related to your education.

Provide a description for any other education-related expenses not specified as tuition, books, supplies, or fees.

Enter the monthly cost for the other education-related expenses described.

Enter the total monthly cost for all education expenses.

Enter the name of the creditor for the eighth unsecured debt.

Enter the last four digits of the account number for the eighth unsecured debt.

Check this box if the eighth unsecured debt is solely in the Petitioner's name.

Check this box if the eighth unsecured debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the eighth unsecured debt is in the names of both Petitioner and Co-Petitioner/Respondent.

Enter the date of the balance for the eighth unsecured debt.

Enter the total outstanding balance for the eighth unsecured debt.

Enter the minimum monthly payment required for the eighth unsecured debt.

Enter the reason for which the eighth unsecured debt was incurred.

Enter the full name of the creditor for the eleventh unsecured debt.

Provide the last four digits of the account number for this unsecured debt.

Check this box if the eleventh unsecured debt is solely in the name of the Petitioner.

Check this box if the eleventh unsecured debt is solely in the name of the Co-Petitioner or Respondent.

Check this box if the eleventh unsecured debt is in the names of both the Petitioner and Co-Petitioner/Respondent (Joint).

Enter the date on which the balance of this unsecured debt was recorded.

Provide the outstanding balance for this unsecured debt.

Enter the minimum monthly payment required for this unsecured debt.

Explain the reason why this unsecured debt was incurred.

Enter the number of hours you work per week on average. Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if you are paid on a weekly basis. Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if you are paid every two weeks (bi-weekly). Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if you are paid twice a month (semi-monthly). Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if you are paid once a month. Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if your pay is a fixed monthly salary. Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if you are paid by the hour (enter your hourly rate). Fill only if 'Not currently employed (I am not)' is 'No'.

Enter your hourly pay rate in dollars. Fill only if 'Not currently employed (I am not)' is 'No'.

Check this box if your pay is based on another arrangement and specify that arrangement. Fill only if 'Not currently employed (I am not)' is 'No'.

If your pay is based on a method other than monthly salary or hourly rate, describe that pay arrangement here. Fill only if 'Not currently employed (I am not)' is 'No'.

Enter the date when this employment began. Fill only if 'Not currently employed (I am not)' is 'No'.

Enter your job title or primary occupation for this employment. Fill only if 'Not currently employed (I am not)' is 'No'.

Enter the full name of your employer or the company that employs you. Fill only if 'Not currently employed (I am not)' is 'No'.

Enter the employer's full mailing address including street, city, and state. Fill only if 'Not currently employed (I am not)' is 'No'.

Enter the monthly amount withheld for federal income tax for this individual.

Enter the monthly amount withheld for state or local income tax for this individual.

Enter the name of the creditor for the fifteenth unsecured debt.

Enter the last four digits of the account number for the fifteenth unsecured debt.

Check this box if the fifteenth unsecured debt is solely in the Petitioner's name.

Check this box if the fifteenth unsecured debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the fifteenth unsecured debt is a joint account.

Enter the date when the balance for the fifteenth unsecured debt was determined.

Enter the outstanding balance for the fifteenth unsecured debt.

Enter the minimum monthly payment required for the fifteenth unsecured debt.

Enter the reason for which the fifteenth unsecured debt was incurred.

Enter a description of the fifth personal property item, including details such as type (e.g., jewelry, antiques, collectibles, artwork, or power tools).

Check this box if the fifth item of furniture, household goods, or other personal property is owned by the Petitioner.

Check this box if the fifth item of furniture, household goods, or other personal property is owned by the Co-Petitioner or Respondent.

Check this box if the fifth item of furniture, household goods, or other personal property is jointly owned.

Check this box if the fifth item of furniture, household goods, or other personal property is currently possessed by the Petitioner.

Check this box if the fifth item of furniture, household goods, or other personal property is currently possessed by the Co-Petitioner or Respondent.

Check this box if the fifth item of furniture, household goods, or other personal property is currently jointly possessed.

Enter the estimated value of the fifth personal property item, representing what you could sell it for in its current condition.

Enter the name of the creditor for the fifth unsecured debt.

Enter the last four digits of the account number for the fifth unsecured debt.

Check this box if the fifth unsecured debt is solely in the Petitioner's name.

Check this box if the fifth unsecured debt is in the name of the Co-Petitioner or Respondent.

Check this box if the fifth unsecured debt is a joint account.

Enter the date of the balance for the fifth unsecured debt.

Enter the current balance for the fifth unsecured debt.

Enter the minimum monthly payment required for the fifth unsecured debt.

Enter the reason for which the fifth unsecured debt was incurred.

Check this box if the first cash or financial account listed belongs to the Petitioner.

Check this box if the first cash or financial account listed belongs to the Co-Petitioner or Respondent.

Check this box if the first cash or financial account listed is jointly owned.

Provide the type of the first cash, checking, savings, or health account.

Enter the last four digits of the first cash, checking, savings, or health account number.

Provide the current balance of the first cash, checking, savings, or health account.

Enter the name of the life insurance company or the beneficiary for the first life insurance policy.

Check this box if the first listed life insurance policy is owned by the Petitioner.

Check this box if the first listed life insurance policy is owned by the Co-Petitioner/Respondent.

Check this box if the first listed life insurance policy is owned Jointly.

Enter the type of the first life insurance policy.

Enter the face amount of the first life insurance policy.

Enter the current cash value of the first life insurance policy.

Enter the year, make, and model of the first motor or recreation vehicle, along with the name of any creditor or lender.

Check this box if the first motor vehicle or recreation vehicle is owned by the Petitioner, or was acquired by the Petitioner before marriage/civil union or as a gift/inheritance, or if the parties were never married and this is the Petitioner's asset.

Check this box if the first motor vehicle or recreation vehicle is owned by the Co-Petitioner or Respondent, or was acquired by the Co-Petitioner/Respondent before marriage/civil union or as a gift/inheritance, or if the parties were never married and this is the Co-Petitioner/Respondent's asset.

Check this box if the parties are married or partners in a civil union and the first motor vehicle or recreation vehicle was acquired jointly during the marriage/civil union but not by gift or inheritance.

Enter the estimated current market value of the first motor or recreation vehicle.

Enter the amount currently owed on the first motor or recreation vehicle.

Enter the net value or equity of the first motor or recreation vehicle, calculated as the estimated value minus the amount owed.

Provide a detailed description of the first personal property item.

Check this box if the first personal property item is owned by the Co-Respondent or Respondent.

Check this box if the first personal property item is owned Jointly.

Check this box if the first personal property item is currently possessed by the Petitioner.

Check this box if the first personal property item is currently possessed by the Co-Respondent or Respondent.

Check this box if the first personal property item is currently possessed Jointly.

Enter the estimated value of the first personal property item as of today.

Enter the address or property description of the first real estate asset, including the name of any associated creditor or lender.

Check this box if the first real estate asset is owned by the Petitioner, or if it was acquired by the Petitioner before marriage/civil union, or as a gift/inheritance.

Check this box if the first real estate asset is owned by the Co-Petitioner or Respondent, or if it was acquired by them before marriage/civil union, or as a gift/inheritance.

Check this box if the first real estate asset was acquired jointly during the marriage or civil union, and not by gift or inheritance.

Enter the estimated market value of the first real estate asset as of today.

Enter the total amount owed on the first real estate asset.

Enter the net value or equity of the first real estate asset, calculated as its estimated value minus the amount owed.

Enter the name of the creditor for the first unsecured debt.

Enter the last four digits of the account number for the first unsecured debt.

Check this box if the first unsecured debt is in the petitioner's name.

Check this box if the first unsecured debt is in the co-petitioner's or respondent's name.

Check this box if the first unsecured debt is a joint debt.

Enter the date of the balance for the first unsecured debt.

Enter the current balance of the first unsecured debt.

Enter the minimum monthly payment required for the first unsecured debt.

Enter the reason for which the first unsecured debt was incurred.

Enter the monthly dollar amount withheld for the Flex Benefit Cafeteria Plan for this voluntary deductions row.

Provide a short description or name of the 'Other' voluntary deduction associated with this row.

Enter the monthly dollar amount for the 'Other' voluntary deduction described in the adjacent field.

Enter the name of the creditor for the fourteenth unsecured debt.

Enter the last four digits of the account number for the fourteenth unsecured debt.

Check this box if the Fourteenth Unsecured Debt belongs to the Petitioner.

Check this box if the Fourteenth Unsecured Debt belongs to the Co-Petitioner or Respondent.

Check this box if the Fourteenth Unsecured Debt is a joint account.

Enter the date as of which the balance for the fourteenth unsecured debt was calculated.

Enter the outstanding balance for the fourteenth unsecured debt.

Enter the minimum monthly payment required for the fourteenth unsecured debt.

Enter the reason for which the fourteenth unsecured debt was incurred.

Enter the name of the bank or financial institution for the fourth cash or financial account.

Check this box if the fourth listed cash, bank, checking, savings, or health account belongs solely to the Petitioner.

Check this box if the fourth listed cash, bank, checking, savings, or health account belongs solely to the Co-Petitioner or Respondent.

Check this box if the fourth listed cash, bank, checking, savings, or health account is owned jointly by both parties.

Enter the type of the fourth cash or financial account (e.g., checking, savings, health account).

Enter the last four digits of the account number for the fourth cash or financial account.

Enter the current balance of the fourth cash or financial account as of today.

Enter the year, make, and model of the fourth motor vehicle or recreation vehicle, along with the name of any creditor or lender.

Check this box if the fourth motor or recreation vehicle was owned by the Petitioner before the marriage/civil union, or if it was acquired by the Petitioner as a gift or inheritance, or if the parties were never married and the Petitioner owns this fourth vehicle.

Check this box if the fourth motor or recreation vehicle was owned by the Co-Petitioner or Respondent before the marriage/civil union, or if it was acquired by the Co-Petitioner or Respondent as a gift or inheritance, or if the parties were never married and the Co-Petitioner or Respondent owns this fourth vehicle.

Check this box if the parties are married or in a civil union and the fourth motor or recreation vehicle was acquired jointly during the marriage/civil union, and not by gift or inheritance.

Enter the estimated current market value of the fourth motor vehicle or recreation vehicle.

Enter the amount currently owed on the fourth motor vehicle or recreation vehicle.

Enter the net value or equity of the fourth motor vehicle or recreation vehicle.

Enter any additional value or amount related to the fourth motor vehicle or recreation vehicle.

Check this box if the Fourth Personal Property Item is attributed to the Petitioner.

Check this box if the Fourth Personal Property Item is attributed to the Community or Respondent.

Check this box if the Fourth Personal Property Item is attributed jointly.

Check this box if the Fourth Personal Property Item is currently possessed by the Petitioner.

Check this box if the Fourth Personal Property Item is currently possessed by the Community or Respondent.

Check this box if the Fourth Personal Property Item is currently possessed jointly.

Provide the name of the creditor for this fourth unsecured debt.

Provide the last four digits of the account number for this fourth unsecured debt.

Check this box if the fourth unsecured debt is solely associated with the Petitioner.

Check this box if the fourth unsecured debt is associated with the Co-Petitioner or Respondent.

Check this box if the fourth unsecured debt is a joint account.

Enter the date when the balance for this fourth unsecured debt was recorded.

Provide the total outstanding balance for this fourth unsecured debt.

Provide the minimum monthly payment required for this fourth unsecured debt.

Explain the reason why this fourth unsecured debt was incurred.

Enter the monthly amount you pay for gas and electricity for the household.

Enter the monthly amount you pay for water, sewer, and trash removal services.

Enter the monthly amount you spend on groceries and household supplies.

Enter the monthly amount you spend on eating out, takeout, and restaurant meals.

Enter the monthly cost you pay for health, dental, and vision insurance premiums for the voluntary deduction on this row.

Enter the monthly amount withheld for retirement and deferred compensation for the voluntary deduction on this row.

Enter the monthly amount you pay for home or rental insurance and property taxes that are not included in your mortgage payment.

Enter the monthly condo, homeowner association, or regular maintenance fees you pay for your property.

Enter the monthly dollar amount you pay for Internet, cable, or satellite TV service for this entry.

Provide a short description of the 'Other' service or fee related to Internet/cable/satellite (for example, provider name, service type, or a note about the charge).

Enter the monthly dollar amount for the 'Other' Internet/cable/satellite-related charge described in the adjacent field.

Enter the monthly cost amount you pay for life and disability insurance for this voluntary deduction row.

Enter the monthly cost amount you pay for stocks or bonds withheld as a voluntary deduction for this row.

Check this box if you have no life insurance to declare.

Enter the total face amount of all listed life insurance policies.

Enter the total current cash value of all listed life insurance policies.

Check this box if maintenance payments are made to this family.

Check this box if maintenance payments are made to an other family.

Check this box if child support payments are made to this family.

Check this box if child support payments are made to an other family.

Enter the monthly dollar amount withheld for Medicare Tax in the left Cost Per Month column for this mandatory row.

Enter the monthly dollar amount for any other mandatory deduction listed on this row (Other) in the middle Cost Per Month column.

Enter the monthly dollar amount for the rightmost Cost Per Month column associated with this mandatory row (Medicare/Other as applicable).

Check this box if the document was served on the other party by hand delivery.

Check this box if the document was served on the other party by e-filing.

Check this box if the document was served on the other party by faxing it to the specified number.

Please enter the fax number to which the document was faxed.

Check this box if the document was served on the other party by placing it in the United States mail, postage prepaid, and addressed to the recipient.

Check this box if you own Business Interests and need to report their value.

Check this box if you own Country Club & Other Memberships and need to report their value.

Check this box if you own Oil and Gas Rights and need to report their value.

Check this box if you own Frequent Flyer Miles and need to report their value.

Check this box if you own other miscellaneous assets not listed and need to report their value.

Enter the name or description of the first other miscellaneous asset not listed.

Check this box if you own Stock Options and need to report their value.

Check this box if you own Livestock, Crops, or Farm Equipment and need to report their value.

Check this box if you own Vacation Club Points and need to report their value.

Check this box if you own Education Accounts and need to report their value.

Check this box if you own other miscellaneous assets not listed and need to report their value.

Enter the name or description of the second other miscellaneous asset not listed.

Check this box if you own money or loans owed to you and need to report their value.

Check this box if you own a pending lawsuit or claim and need to report its value.

Check this box if you have a Safety Deposit Box/Vault containing assets that need to be reported.

Check this box if you own Health Savings Accounts and need to report their value.

Check this box if you own other miscellaneous assets not listed and need to report their value.

Enter the name or description of the third other miscellaneous asset not listed.

Check this box if you own RS Refunds due to you and need to report their value.

Check this box if you own Accrued Paid Leave (sick, vacation, personal) and need to report its value.

Check this box if you are a Trust Beneficiary and need to report the value of your beneficial interest.

Check this box if you own Mineral and Water Rights and need to report their value.

Check this box if you own other miscellaneous assets not listed and need to report their value.

Enter the name or description of the fourth other miscellaneous asset not listed.

Enter the total value of all miscellaneous assets.

Enter the monthly cost for recreation and entertainment.

Enter the monthly cost for legal and accounting fees.

Enter the monthly cost for charity and worship contributions.

Enter the monthly cost for vacation, travel, and hobbies.

Enter the monthly cost for memberships and clubs.

Enter the monthly cost for pets and pet care.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 7'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 9'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 11'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 13'.

Enter the monthly cost for personal care expenses, including hair, nail, and clothing.

Enter the monthly cost for subscriptions, such as newspapers or magazines.

Enter the monthly cost for movie and video rentals.

Enter the monthly cost for investments that are not part of payroll deductions.

Enter the monthly cost for home furnishings.

Enter the monthly cost for sports events or participation.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 21'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 23'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 25'.

Enter the monthly cost for the miscellaneous expense labeled 'Other - 27'.

Enter the monthly dollar amount of child support received from persons other than the primary payor that you receive for children in this household.

Enter the monthly dollar amount for any other miscellaneous income related to this row (specify source if required) that is not captured in the labeled categories.

Enter the total monthly dollar amount representing the sum of the miscellaneous income amounts in this section.

Enter the source or brief description of the dependent children's monthly income (for example: child support, SSI, trust, employment, etc.). Fill only if 'Household minor children' is greater than 0.

Enter the total monthly gross income amount received for the dependent children. Fill only if 'Household minor children' is greater than 0.

Enter the total monthly amount from all other sources (for example: personal injury settlement, non‑reported income, miscellaneous payments).

Enter the monthly net rental income amount you receive from the rental property.

List the expense accounts or descriptions used for the rental property (for example: maintenance, utilities, property management).

Enter the total monthly amount you receive from royalties, trusts, investment income, or other similar investment sources.

Enter the monthly dollar amount contributed to your household by other people (gifts, support, or contributions from friends/family/others).

Enter the monthly amount of spousal or partner support the Petitioner receives from others.

Enter the monthly amount of spousal or partner support the Co‑Petitioner/Respondent receives from others.

Enter the combined total monthly amount of spousal or partner support from others for all parties.

Enter the total monthly miscellaneous income from all non-wage sources (royalties, trusts, child support from others, rental net income, contributions, etc.) to include on the financial statement.

Enter the overall total monthly income amount that combines all income categories (gross wages, benefits, retirement, and miscellaneous income) for the financial statement.

Enter the total gross monthly income before taxes and deductions from salary and wages, including commissions, bonuses, overtime, self-employment or business income, other jobs, and monthly reimbursed expenses.

Check this box if you receive Social Security Disability Insurance (SSDI) benefits and should include that amount as part of your monthly Social Security benefits.

Check this box if you receive Supplemental Security Income (SSI) benefits and should include that amount as part of your monthly Social Security benefits.

Enter the total monthly amount received in Social Security benefits (e.g., SSDI or SSI) for the household member.

Enter the total monthly amount you receive from pensions and retirement accounts converted to a monthly figure.

Enter the total monthly amount you receive from interest and dividends converted to a monthly figure.

Enter the monthly amount received from Public Assistance (TANF) for the appropriate column/party shown on the form.

Enter any other monthly income amount that belongs in the middle column (e.g., other income for the Petitioner or Co‑Petitioner as indicated on the form).

Enter any other monthly income amount that belongs in the right-hand column (e.g., other income for the other party or the row total, as shown on the form).

Enter the total monthly income (the combined/monthly sum of all income rows) for the column indicated on the form.

Enter the total monthly amount you receive from unemployment benefits and/or veterans' benefits before taxes and deductions.

Enter the total monthly amount you receive from disability payments and/or workers' compensation before taxes and deductions.

Check this box if you or the other party do not have any motor vehicles or recreation vehicles to report in this section.

Enter the total estimated current value of all motor and recreation vehicles.

Enter the total amount owed for all motor and recreation vehicles.

Enter the total net value or equity for all motor and recreation vehicles.

Provide the net excess or shortfall amount, calculated as monthly net income less monthly expenses and payments.

Enter the name of the creditor for the ninth unsecured debt.

Provide the last four digits of the account number for the ninth unsecured debt.

Check this box if the ninth unsecured debt is solely in the Petitioner's name.

Check this box if the ninth unsecured debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the ninth unsecured debt is in the names of both Petitioner and Co-Petitioner/Respondent (Joint).

Enter the date when the balance for the ninth unsecured debt was recorded.

Enter the outstanding balance of the ninth unsecured debt.

Enter the minimum monthly payment required for the ninth unsecured debt.

Explain the reason for which the ninth unsecured debt was incurred.

Check this box if you do not have any pension, profit sharing, or retirement funds to declare.

Check this box if you own pension, profit sharing, or retirement funds and need to attach form JDF 1111-SS.

Enter the total estimated value of all pension, profit sharing, or retirement funds.

Enter the monthly dollar amount withheld for PERA/Civil Service contributions for this employee.

Enter the monthly dollar amount withheld for Social Security Tax for this employee.

Check this box if you have no furniture, household goods, or other personal property to declare in this section.

Enter the total estimated value of all furniture, household goods, and other personal property.

Enter the total amount carried forward from the previous page.

Check this box if neither you nor the other party has any real estate assets to disclose.

Enter the total estimated value of all real estate assets as of today.

Enter the total amount owed on all real estate assets.

Enter the total net value or equity of all real estate assets.

Enter the monthly rent amount you pay for housing for this row.

Enter the name or brief description of the other housing expense you want to record on this row.

Enter the monthly cost for the other housing expense listed in the adjoining description field.

Enter the name of the bank or financial institution for the second cash or financial account.

Check this box if the second cash or financial account listed was owned by the Petitioner, or was acquired by the Petitioner as a gift or inheritance.

Check this box if the second cash or financial account listed was owned by the Co-Petitioner or Respondent, or was acquired by them as a gift or inheritance.

Check this box if the second cash or financial account listed was acquired jointly by the Petitioner and Co-Petitioner/Respondent during their marriage or civil union, and was not acquired by gift or inheritance.

Enter the type of the second cash or financial account, such as checking, savings, or health account.

Enter the last four digits of the account number for the second cash or financial account.

Enter the current balance of the second cash or financial account as of today.

Provide the name of the insurance company or the beneficiary for the second life insurance policy.

Check if this second life insurance policy is attributed to the primary party (P).

Check if this second life insurance policy is community property or attributed to a specific recipient (C/R).

Check if this second life insurance policy is held jointly by multiple parties (J).

Enter the type of the second life insurance policy.

Provide the face amount of the second life insurance policy.

Enter the current cash value of the second life insurance policy.

Enter the year, make, model, and the name of the creditor or lender for the second motor vehicle or recreation vehicle.

Check this box if the second motor vehicle or recreation vehicle is owned by the Petitioner.

Check this box if the second motor vehicle or recreation vehicle is owned by the Co-Petitioner or Respondent.

Check this box if the second motor vehicle or recreation vehicle is owned jointly by the parties.

Provide the estimated current market value of the second motor vehicle or recreation vehicle.

Specify the total amount currently owed on the second motor vehicle or recreation vehicle.

Enter the net value or equity of the second motor vehicle or recreation vehicle, which is the estimated value minus the amount owed.

Provide any additional relevant details or notes regarding the second motor vehicle or recreation vehicle.

Enter a detailed description of the second personal property item.

Check this box if the second personal property item listed is owned by the Petitioner.

Check this box if the second personal property item listed is owned by the Co-Petitioner or Respondent.

Check this box if the second personal property item listed is jointly owned.

Check this box if the second personal property item listed is currently possessed by the Petitioner.

Check this box if the second personal property item listed is currently possessed by the Co-Petitioner or Respondent.

Check this box if the second personal property item listed is currently jointly possessed.

Enter the estimated value of the second personal property item as of today.

Enter the address or property description of the second real estate asset and the name of any creditor or lender associated with it.

Check this box if the second real estate asset is owned by the Petitioner.

Check this box if the second real estate asset is owned by the Co-Petitioner or Respondent.

Check this box if the second real estate asset is owned jointly by the Petitioner and Co-Petitioner/Respondent.

Enter the estimated market value of the second real estate asset as of today.

Enter the total amount currently owed on the second real estate asset.

Enter the net value or equity of the second real estate asset, calculated as its estimated value minus the amount owed.

Enter the name of the creditor for the second unsecured debt.

Enter the last 4 digits of the account number for the second unsecured debt.

Check this box if the second unsecured debt is solely in the Petitioner's name.

Check this box if the second unsecured debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the second unsecured debt is in joint names.

Enter the date as of which the balance for the second unsecured debt is recorded.

Enter the total outstanding balance for the second unsecured debt.

Enter the minimum monthly payment required for the second unsecured debt.

Provide the reason for which the second unsecured debt was incurred.

Check this box if there is no separate property to declare.

Check this box if separate property is owned, and you need to attach JDF 1111-SS to identify the property and report its value.

Enter the total monetary value of all separate property assets.

Enter the full name of the service recipient to whom the documents are being mailed.

Enter the street number and street name of the service recipient's mailing address.

Enter the city for the service recipient's mailing address.

Enter the state for the service recipient's mailing address.

Enter the zip code for the service recipient's mailing address.

Enter the name of the creditor for the seventh unsecured debt.

Enter the last four digits of the account number for the seventh unsecured debt.

Check this box if the seventh listed unsecured debt is in the petitioner's name only.

Check this box if the seventh listed unsecured debt is in the co-petitioner's or respondent's name only.

Check this box if the seventh listed unsecured debt is a joint debt.

Enter the date of the balance for the seventh unsecured debt.

Enter the total outstanding balance for the seventh unsecured debt.

Enter the minimum monthly payment required for the seventh unsecured debt.

Provide the reason for which the seventh unsecured debt was incurred.

Enter the name of the creditor for the sixth unsecured debt.

Enter the last four digits of the account number for the sixth unsecured debt.

Check this box if the Sixth Unsecured Debt is solely in the Petitioner's name.

Check this box if the Sixth Unsecured Debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the Sixth Unsecured Debt is a joint account.

Enter the date the balance was recorded for the sixth unsecured debt.

Enter the total outstanding balance for the sixth unsecured debt.

Enter the minimum monthly payment required for the sixth unsecured debt.

Enter the reason for which the sixth unsecured debt was incurred.

Check this box if you do not own any stocks, bonds, mutual funds, securities, or investment accounts.

Check this box if you own stocks, bonds, mutual funds, securities, or investment accounts and are attaching JDF 1111-SS.

Enter the total estimated value of all stocks, bonds, mutual funds, securities, and investment accounts.

Check this box if you are currently enrolled as a full-time student.

Check this box if you are currently enrolled as a part-time student.

Enter the monthly amount you pay for telephone services (local, long distance, cellular & pager).

Enter the monthly amount you pay for property care (lawn care, snow removal, cleaning, security system, etc.).

Enter the name of the creditor for the tenth unsecured debt.

Enter the last four digits of the account number for the tenth unsecured debt.

Check this box if the tenth unsecured debt is solely in the Petitioner's name.

Check this box if the tenth unsecured debt is in the name of a Co-Petitioner or Respondent.

Check this box if the tenth unsecured debt is in joint names.

Enter the date of the balance for the tenth unsecured debt.

Enter the outstanding balance for the tenth unsecured debt.

Enter the minimum monthly payment required for the tenth unsecured debt.

Enter the reason why the tenth unsecured debt was incurred.

Enter the name of the bank or financial institution for this third cash or financial account.

Check this box if the third cash or financial account is owned solely by the Petitioner, or was owned by the Petitioner before marriage/civil union, or was acquired by the Petitioner as a gift or inheritance.

Check this box if the third cash or financial account is owned solely by the Co-Petitioner or Respondent, or was owned by the Co-Petitioner/Respondent before marriage/civil union, or was acquired by the Co-Petitioner/Respondent as a gift or inheritance.

Check this box if the third cash or financial account is owned jointly by both parties, and was acquired during marriage/civil union not by gift or inheritance.

Specify the type of this third cash or financial account.

Provide the last four digits of the account number for this third cash or financial account.

Enter the current balance of this third cash or financial account as of today's date.

Enter the name of the company or the beneficiary for the third life insurance policy.

Check this box if the primary individual is associated with this third life insurance policy.

Check this box if this third life insurance policy is community property or relates to a specific recipient.

Check this box if this third life insurance policy is jointly owned or jointly associated with another party.

Enter the type of the third life insurance policy.

Enter the face amount of the third life insurance policy.

Enter the current cash value of the third life insurance policy.

Please provide the year, make, model, and name of the creditor or lender for the third motor vehicle or recreation vehicle.

Check this box if the third motor or recreation vehicle listed was owned by the Petitioner before the marriage/civil union, or was acquired by the Petitioner through gift or inheritance.

Check this box if the third motor or recreation vehicle listed was owned by the Co-Petitioner or Respondent before the marriage/civil union, or was acquired by the Co-Petitioner or Respondent through gift or inheritance.

Check this box if the third motor or recreation vehicle listed was acquired jointly by the parties during the marriage or civil union, and not by gift or inheritance.

Please enter the estimated current market value of the third motor vehicle or recreation vehicle.

Please enter the outstanding amount owed on the third motor vehicle or recreation vehicle.

Please enter the net value or equity of the third motor vehicle or recreation vehicle, calculated as its estimated value minus the amount owed.

Please enter any reference identification number or specific identifier for the third motor vehicle or recreation vehicle.

Enter the address or property description and the name of the creditor or lender for the third real estate asset.

Check this box if the third real estate asset is owned by the Petitioner, especially if acquired before marriage/civil union or by gift/inheritance, or if the parties were never married.

Check this box if the third real estate asset is owned by the Co-Petitioner/Respondent, especially if acquired before marriage/civil union or by gift/inheritance, or if the parties were never married.

Check this box if the third real estate asset was acquired jointly during a marriage or civil union and not by gift or inheritance.

Enter the estimated market value of the third real estate asset as of today, representing what it could sell for in its current condition.

Enter the total amount owed on the third real estate asset.

Enter the net value or equity of the third real estate asset, calculated as its estimated value minus the amount owed.

Enter the name of the creditor for the third unsecured debt.

Enter the last four digits of the account number for the third unsecured debt.

Check this box if the third unsecured debt is owed by the Petitioner.

Check this box if the third unsecured debt is owed by the Co-Petitioner or Respondent.

Check this box if the third unsecured debt is owed jointly.

Enter the date as of which the balance of the third unsecured debt is reported.

Enter the outstanding balance of the third unsecured debt.

Enter the minimum monthly payment required for the third unsecured debt.

Provide the reason for which the third unsecured debt was incurred.

Enter the name of the creditor for the thirteenth unsecured debt.

Enter the last 4 digits of the account number for the thirteenth unsecured debt.

Check this box if the thirteenth unsecured debt is solely in the Petitioner's name.

Check this box if the thirteenth unsecured debt is solely in the Co-Petitioner's or Respondent's name.

Check this box if the thirteenth unsecured debt is in the names of both the Petitioner and Co-Petitioner/Respondent (Joint account).

Enter the date of the balance for the thirteenth unsecured debt.

Enter the current balance for the thirteenth unsecured debt.

Enter the minimum monthly payment required for the thirteenth unsecured debt.

Enter the reason for which the thirteenth unsecured debt was incurred.

Enter the total monthly amount you spend on groceries, household supplies, and dining out combined.

Enter the total monthly housing expense amount that sums all housing-related costs on this page (mortgages, insurance and property taxes, rent, condo/homeowner’s/maintenance fees, and any other housing charges).

Enter the total monthly dollar amount of all mandatory deductions (the sum of Federal Income Tax, State/Local Income Tax, PERA/Civil Service, Social Security Tax, Medicare Tax, Other mandatory deductions).

Enter the total amount for miscellaneous expenses.

Enter the total dollar amount of all mandatory and voluntary deductions taken from your pay each month (sum of the section above).

Enter the total amount for all monthly deductions.

Enter the total of all monthly expenses from sections A through I.

Enter the total sum of all monthly expenses and payments.

Provide the total amount of all monthly expenses as calculated from Page 3.

Enter the total monthly net income, calculated as Total Income (A) minus Total Monthly Deductions (B).

Enter the total number of people (count) who are covered on the plan for this voluntary deduction row.

Enter the combined total monthly cost you pay for all utilities and miscellaneous housing services (e.g., gas, electricity, water, sewer, trash removal, telephone, internet, property care) as a single numeric amount.

Enter the total value or balance of all assets from sections A through H.

Enter the total monthly dollar amount of all voluntary deductions (sum of the voluntary deduction line items) as a numeric value.

Enter the monthly payment for your primary vehicle.

Enter the monthly cost for fuel, parking, and vehicle maintenance.

Enter the monthly cost for bus passes and other commuter fees.

Enter the monthly payment for any other vehicles.

Enter the monthly cost for vehicle insurance, registration, and tax payments.

Enter the monthly cost for any other transportation expenses not listed.

Enter the total monthly cost for all transportation expenses.

Enter the name of the creditor for the twelfth unsecured debt.

Provide the last four digits of the account number for the twelfth unsecured debt.

Check this box if the twelfth unsecured debt is solely on account of the Petitioner.

Check this box if the twelfth unsecured debt is solely on account of the Co-Petitioner or Respondent.

Check this box if the twelfth unsecured debt is on a joint account.

Enter the date as of which the balance of the twelfth unsecured debt was determined.

Enter the current outstanding balance for the twelfth unsecured debt.

Enter the minimum monthly payment required for the twelfth unsecured debt.

Explain the reason for which the twelfth unsecured debt was incurred.

Enter the date you last worked before becoming unemployed. Fill only if 'Not currently employed (I am not)' is 'Yes'.

Check this box if you are currently unemployed because of a disability. Fill only if 'Not currently employed (I am not)' is 'Yes'.

Check this box if you are currently unemployed because you were involuntarily laid off from your job. Fill only if 'Not currently employed (I am not)' is 'Yes'.

Check this box if you are unemployed for a reason other than disability or layoff and write the reason on the provided line. Fill only if 'Not currently employed (I am not)' is 'Yes'.

If you selected 'Other' for the reason you are unemployed, briefly describe that reason. Fill only if 'Not currently employed (I am not)' is 'Yes'.

Enter the total number of adults who live in your household.

Enter the total number of minor children who live in your household.

Provide the other party's monthly gross income as a numeric value.

Enter the last two digits of the tax year for the annual gross income being reported (for example, '23' for 2023).

Enter the Petitioner's annual gross income for the last tax year as a numeric value.

Check this box to indicate the annual gross income amount entered applies to the Co‑Petitioner/Respondent.

Enter the Co‑Petitioner or Respondent's annual gross income for the last tax year as a numeric value.

Enter the total balance of all unsecured debts.

Enter the total minimum monthly payment required for all unsecured debts.

Enter the day of the month the document was executed.

Enter the month the document was executed.

Enter the year the document was executed.

Enter the city or other location, and the state or country, where the document was executed.

Enter the printed name of the Petitioner, Co-Petitioner, or Respondent.

Enter the signature of the Petitioner, Co-Petitioner, or Respondent.