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Pennsylvania Divorce Worksheet

Your Information

Name: __________________________________________

Address: __________________________________________

__________________________________________

DOB: __________________________________________

Phone: __________________________________________

Email: __________________________________________

Your Spouse

Name: __________________________________________

Address: __________________________________________

__________________________________________

DOB: __________________________________________

Information About Your Marriage

Date of Marriage: __________________________________________

City, State and County of Marriage: __________________________________________

Previous marriages? __________________________________________

Spousal Support Sought

Custodial parent will seek spousal support in the amount of $___________ per month.

Custody

Who will have custody of the children? _________________________________

Who will pay child support? _________________________________

Child Support

[ ] My spouse and I agree on child support in the amount of $_________ for all children listed. (We still must complete a child support worksheet for you and the court can still order support according to state guidelines.)

OR

[ ] Child support will be computed based on the state guidelines.

When will support begin? _________________________________

Which day of the month will support be due? _________________________________

Life Insurance and Medical Information for Children

Who will provide medical insurance for the children? _________________________________

Dental? _________________________________ Vision? _________________________________

Is this insurance available through employment or union? _______Yes _______No

For uncovered medical, dental and vision expenses, husband will pay ________% and wife will pay ________%.

Will the parent paying child support be required to maintain life insurance? _______________

If yes, how much? $_____________________

Tax Matters

The children will be claimed as dependents for taxes as follows:

[ ] Mother will claim the children.

[ ] Father will claim the children.

[ ] We will alternate claiming the children.

[ ] We will each claim one or more of the children.

Father will claim the following children: ______________________________________________

Mother will claim the following children: ______________________________________________

Marital Home

[ ] You will remain in the marital home.

[ ] Your spouse will remain in the marital home.

[ ] The home will be sold, and the net proceeds will be divided in the following percentages:

You: _________% Your spouse: _________%

Your Children

Please provide the name, date of birth, social security number and name of parent(s) (if different than the above listed parties) of your children:

Name: __________________________________________

DOB: __________________________________________

SSN: __________________________________________

Parent(s): __________________________________________

Name: __________________________________________

DOB: __________________________________________

SSN: __________________________________________

Parent(s): __________________________________________

Name: __________________________________________

DOB: __________________________________________

SSN: __________________________________________

Parent(s): __________________________________________

Name: __________________________________________

DOB: __________________________________________

SSN: __________________________________________

Parent(s): __________________________________________

Child Support Computation Information

Gross income for each party: Mother: $_______________ Father: $_______________

Name of employer:

Mother: __________________________________________

Father: __________________________________________

Child care costs (day care costs needed while a parent works or seeks employment). Indicate amount and which parent pays.

Amount: $______________________

Paid by: __________________________________________

Number of children under age 21 from other marriages or relationships that each parent has to support:

Mother: __________________________________________

Father: __________________________________________

Amount paid for health insurance for children

Amount: $______________________

Paid by: __________________________________________

If this parent is required to maintain his/her own health insurance in order to insure the child, what is the amount paid for this parent’s insurance?

Amount: $______________________

Amount of spousal support or alimony either parent is paying or receiving:

Amount: $______________________

Paid by: __________________________________________

Amount of Social Security or Veterans Benefits, if any, received:

Amount: $______________________

Financial Information

Balance Sheet

Assets

Spouse 1

Spouse 2

Joint

House

Checking accounts

Savings accounts

Certificates of Deposit

Stocks

Bonds

IRAs

Retirement plans

Pension plans

Life insurance

Business property

Accounts receivable

Loans (lender)

Vehicles

Boats

Jewelry

Clothing

Sporting equipment

Collections

Other assets

Total Assets:

Liabilities

Real estate mortgage:________________________________________________________________

Home equity loan: ________________________________________________________________

Credit card debt: ________________________________________________________________

Vehicle loans: ________________________________________________________________

Student loans: ________________________________________________________________

Other debts: ________________________________________________________________

Total Liabilities:

Net Worth (Assets – Liabilities):

$_____________________

Monthly Income

Spouse 1

Spouse 2

Joint

Salary (gross)

Bonuses/Commissions

Investment accounts

Rental property

Other income

Total Income (Monthly):

Monthly Expenses

Spouse 1

Spouse 2

Joint

Housing (mortgage & taxes)

Auto (loans/expenses)

Food

Clothing

Child care & education

Income taxes

Insurance

Utilities

Phone

Health care/medicine

Recreation

Student loans

Home maintenance

Miscellaneous

Total Expenses:

Other Information:

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