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Local Rule - State of Indiana

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D. OTHER EXPENSES1. Food2. Clothing3. Transportation4. Health/medical/dental5. Childcare/daycare6. Personal/entertainmentE. ALL OTHER EXPENSESV. PROVISIONAL ARREARAGE COMPUTATIONS. If you allege the existence <strong>of</strong> 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 <strong>of</strong> receipt <strong>of</strong> the other parties’Financial Declaration Form.VI. VERIFICATIONI declare, under the penalties <strong>of</strong> perjury, that the foregoing, including any valuations andattachments, is true and correct and that I have made a complete and absolute disclosure <strong>of</strong> 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 <strong>of</strong> 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 <strong>Rule</strong> Eleven (11) <strong>of</strong>the <strong>Indiana</strong> <strong>Rule</strong>s <strong>of</strong> Procedure.Date:ATTORNEY’S SIGNATURE24

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