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 |
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 |
( ) week | ( ) two weeks | ( ) bimonthly | ( ) month |
|
HUSBAND |
( ) 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 |
$ |
$ |
|
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 _________ |
