INCOME AND EXPENSE

Name_______________________________________________ Phone # _____________________________

Address___________________________________________________________________________________
__________________________________________________________________________________________

Employer:_________________________________________________Phone #__________________________

Employer’s address:_________________________________________________________________________

Ocupation_________________________________________________ Date job started__________________

If unemployed, date job ended_________________ Number of hours you work per week___________

How much do you get paid? $________ per month______ per week______ per hour______ (check one)

What were your gross monthly earnings last month? ___________ Do you have more than one job?______

Age_____ High School graduate? ________ If not, highest grade completed?____________

Number of years in college________ Degree obtained, if any___________________________

Number of years in Graduate School_____________ Professional license:_________________________

Vocational Training: _________________________________

Last year filed taxes: ________ State of filing______ # of exemptions claimed: ____________

Tax filing status: ______Single ______Head of household ______Married filing separately

______ Married filing jointly

Estimate of the other party’s Gross monthly income: ______________________________________________

Explain how you know this information: _________________________________________________________

Proof of income for the last two months will be required.

INCOME: Last month Average Monthly

Salary or wages (gross, before taxes): $_____________ $___________

Overtime (gross before taxes) $_____________ $___________

Commissions or bonuses $_____________ $___________

Public assistance $_____________ $___________

Spousal Support ____from this marriage ____From a different marriage $_____________ $___________

Partner Support ____From this domestic Part. _____Another $_____________ $___________

Pension/retirement fund payments $_____________ $___________

Disability ___Social Security ____State Disability (SDI) ___Private Insurance $_____________ $___________

Unemployment Compensation $_____________ $___________

Worker’s Compensation $_____________ $___________

Other (Military BAQ, royalty Payments, etc) (specify) $_____________ $___________

INVESTMENTS

Dividends/Interest $_____________ $___________

Rental Property Income $_____________ $___________

Trust Income $_____________ $___________

Other (specify) $_____________ $___________

INCOME FROM SELF EMPLOYMENT

I am the _____owner/sole proprietor ____Business partner ____Other (specify)

Number of years in this business (specify) _________________________________________________________

Type of business (specify) ______________________________________________________________________

Additional income. I received a one time money (lottery winnings, inheritance, etc) in the last 12 months
(specify source and amount)__________________________________________________________________

Change of income. My financial situation has changed significantly over the last 12 months because (specify):

__________________________________________________________________________________________

DEDUCTIONS:

Required union dues: $__________

Required retirement payments (not social security, FICA, 401(k) or IRA) $__________

Medical, hospital, dental, and other health insurance premiums (total monthly amount) $__________

Child support I pay from for children from other relationships $__________

Spousal support I pay by court order from a different marriage $__________

Partner support that I pay by court order from a different domestic partnership $__________

Necessary job-related expenses not reimbursed by my employer $__________

Explain this expenses_________________________________________________________________________

__________________________________________________________________________________________

ASSETS

Cash and checking accounts, savings, credit union, money market and other deposit accounts $___________
Stocks, bonds, and other assets I could easily sell $___________

All other property ____Real ____personal (estimate FMV minus debts owed) $___________

The following people live with me:

Name Age How is related to you Income Pays some expenses?

Average monthly income ___estimated expenses ____Actual Expenses ____Proposed expenses

HOME: _______ Rent ______Mortgage

If mortgage: $___________ average principal $_________Average interest

$___________Property taxes $_________Insurance $_______Maintenance and repair

Health care costs not paid by insurance: $_____________ Child care $________________________

Groceries and household supplies $_____________ Eating out $____________________

Utilities (gas, electric, water, trash) $___________ Telephone, cell phone, and email $__________

Laundry and cleaning $ ___________ Clothes $________ Education $_________

Entertainment, gifts and vacation $______

Auto expenses and transportation (insurance, gas, repairs, bus, etc) $_________

Insurance (life, accident, etc, do not include auto, home, or health insurance) $_______

Savings and investments $____________ Charitable contributions: $ _________

Other (specify): _____________________________ $__________

INSTALMENT PAYMENTS and DEBTS:

Paid to For Amount Balance Date of last Payment

Child Support information:

Number of children _______ Percentage of time with mother __________ with father ________

______ I do _______I do not have health insurance available to me for the children through my job.
Name of insurance company___________________________________________________________________

Address of insurance company_________________________________________________________________

The monthly costs for the children’s health insurance is or would be (specify) $_____________ (do not include the
amount your employer pays).

ADDITIONAL EXPENSES FOR THE CHILDREN :

Child care so I can work or get a job training: $____________

Children’s health insurance care not covered by insurance: $___________

Travel expenses for visitation $___________

Children’s educational or other special needs (specify) _____________________________________________

SPECIAL HARDSHIPS.

Extraordinary health expenses: $__________ per month For ______ months

Major losses not covered by insurance (fire, theft, etc) $__________ ______

Expenses for my minor children who are from other relationships and are living with me: _________________

Names and ages of those children: _____________________________________________________________

Child support I receive for those other children $___________

The expenses listed above are extreme hardship because: __________________________________________

_________________________________________________________________________________________

Other information you want the court to know concerning support: