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Financial Information Statement

NOTICE: This form is to be completed and a copy furnished to opposing counsel and to the Clerk of the Court prior to the hearing. All columns must be totaled. Provide past years IRS returns and 2 most recent payroll stubs and if none, provide W-2 forms.

NO.

___th District Court

_______________
PETITIONER
________________
RESPONDENT
_______________
ATTORNEY
________________
ATTORNEY

1. Date of Marriage:

Date of Separation:

2. Ages of Children:

3. GROSS MONTHLY
RESOURCES:

WIFE

HUSBAND

Wages/Salary

$$

Overtime

$$

Bonus

$$

Commissions/Tips

$$

Interest on Savings

$$

Dividends

$$

Royalty Income

$$

Trust Income

$$

Net Rental Income

$$

Retirement/Pension Income

$$

Annuities

$$

Capital Gains

$$

Social Security Benefits

$$

Unemployment Benefits

$$

Disability/Workman's Comp.

$$

Interest on Notes

$$

Accounts Receivable

$$

Spousal Support/Alimony

$$

Other Income

$$

TOTAL RESOURCES:

$$

4. DEDUCTIONS:

Withholding Tax

$$

FICA

$$

Retirement

$$

Union Dues

$$

Health Insurance

$$

Health Insurance for children

$$

Miscellaneous

$$

TOTAL DEDUCTIONS:

$$

5. NET MONTHLY INCOME:

6. EMPLOYMENT:

WIFE:

HUSBAND:

WIFE
IS PAID
EVERY:

( ) week( ) two weeks( ) bimonthly( ) month

HUSBAND
IS PAID
EVERY:

( ) week( ) two weeks( ) bimonthly( ) month

Date Next Check is Received:

WIFE:HUSBAND:

7. QUICK ASSETS:

WIFEHUSBAND

Cash/Undeposited Checks

$$

Financial Institutions

$$

Other

$$

I can borrow $ on my signature.

8. NECESSARY MONTHLY EXPENSES:

House Payment/Rent

$SUBTOTAL FORWARD$

Utilities

$Clothing$

Food

$Cleaning/Laundry$

Doctor/Dentist/etc.

$Legal Fees$

Insurance Payment

$Gifts$

Car Payments

$Church Support$

Gas/Oil/Parking

$Entertainment/Activities$

Car Maintenance

$for children$

Child Care/School

$Miscellaneous:$

Tuition

$ $

Lunches/Supplies

$

Haircuts

$

SUBTOTAL:

$TOTAL:$

9. DEBTS (OTHER THAN LISTED IN NUMBER 8 ABOVE):

AMOUNTMONTHLY PAYMENT

401K LOAN

$$

TOTAL MONTHLY:

$$

10. GRAND TOTAL MONTHLY EXPENSES: $

11. (ANSWER ONLY IF YOU ANTICIPATE RECEIVING SUPPORT) I feel that the following sums are reasonably necessary or within the ability of my spouse to pay, and it will be fair and equitable to require the following:

EACH PAY PERIODMONTHLY

a. For temporary alimony

$$

b. For child support

++

12. Total lines 11a and 11b

$

$

13. Payee's Net Resources

+

+

14. Total lines 12 and 13

$

$

15. Payor's Net Income

$

$

16. Less Alimony and Support (line 12)

(_________)

(_________)

17. Net Payor after deduction of child
support and alimony

$

$

18. (ANSWER ONLY IF YOU ANTICIPATE PAYING SUPPORT) I feel that a reasonable sum for me to pay weekly or monthly would be:

a. For temporary alimony

$$

b. For child support

++

19. Total lines 18a and 18b

$

$

DATE: __________

WIFE'S SIGNATURE ____________

DATE: __________

HUSBAND'S SIGNATURE _________

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