SCA-FC-106: Financial Statement
Review Date: 05/2014; Revision Date: 05/2014; WVSCA Approved: 06/17/2014
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IN THE FAMILY COURT OF
COUNTY, WEST VIRGINIA
The Marriage / Children Of:
Civil Action No.
This form MUST be completed in ALL DIVORCE, CHILD SUPPORT, AND PATERNITY
The Petitioner and the Respondent must each complete one of these forms.
The completed form MUST be filed in the Circuit Clerk's Office at the time of filing the Petition
for Divorce and/or the Answer to Divorce Petition, and a copy must be served on the opposing party. If
the Bureau For Child Support Enforcement is a party, a copy of the completed form must also be
served on their local office.
If your case involves minor children, or either party requests spousal support, you MUST file
the following information WITH your completed Financial Statement.
1. A copy of your most recent wage or salary stub showing gross pay, deductions for taxes and other
items, and net pay for a normal pay period, and for the year-to-date;
2. Copies of your and your spouse's complete income tax returns for the two years immediately preceding
the date the petition was filed, together with copies of the federal Form W-2 for those years; and a copy
of the Form W-2 for the most recent year for which that form is available, even if a tax return has not
yet been filed for that year;
3. For self-employed persons and business owners, a copy of a current financial statement showing gross
income, expenses, and net income;
4. Copies of any invoices or receipts showing the cost of any extraordinary medical expenses for the party
or the children, of any child care expenses, and of any expenses necessitated by the special needs of the
If the information you provide in this form changes, or any information you file along with this
form changes, you MUST immediately provide the new information. Any updates or changes to the
financial statement must be filed in the Circuit Clerks office, and a copy served on the opposing party,
pursuant to the scheduling order of the Court. If you do not have a scheduling order, then the
information must be filed at least 5 days prior to any hearing.
The information you provide on this form is ONLY for use in the judicial system, and is
required by law and court rule to be kept CONFIDENTIAL.
Check this box if you have filed the Affidavit for Withholding Identifying Information.
If this box is checked you do not have to provide your home or employment address or telephone.