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:	WIFE	HUSBAND
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):

	AMOUNT	MONTHLY 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 PERIOD	MONTHLY
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 _________