Local Rule - State of Indiana

D. OTHER EXPENSES1. Food2. Clothing3. Transportation4. Health/medical/dental5. Childcare/daycare6. Personal/entertainmentE. ALL OTHER EXPENSESV. PROVISIONAL ARREARAGE COMPUTATIONS. If you allege the existence of a childsupport, birthing expenses, past medical bills, daycare expenses, maintenance, or other arrearage,attach all records or other exhibits regarding the payment history and compute the child supportarrearages.You must attach a Child Support guideline Worksheet to your Financial Declaration From or onemust be exchanged with the opposing party/counsel within 10 days of receipt of the other parties’Financial Declaration Form.VI. VERIFICATIONI declare, under the penalties of perjury, that the foregoing, including any valuations andattachments, is true and correct and that I have made a complete and absolute disclosure of all myassets and liabilities. Furthermore, I understand that if, in the future, it is proved to this Court that Ihave intentionally failed to disclose any asset or liability, I may lose the asset and be required to paythe liability. Finally, I acknowledge that sanctions may be imposed against me, including reasonableattorney’s fees and expenses incurred in the investigation, preparation and prosecution of any claimor action that proves my failure to disclose assets or liabilities.Date:PARTY’S SIGNATUREVII. ATTORNEY CERTIFICATIONI have reviewed with my client, the foregoing information, including any valuations andattachments, and have signed this certification with my obligation under Trial Rule Eleven (11) ofthe Indiana Rules of Procedure.Date:ATTORNEY’S SIGNATURE24