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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:

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 _________

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