This form contains Restricted Information. CIRCUIT COURT ...
This form contains Restricted Information.
CIRCUIT COURT FOR
City/County
Located at
Plaintiff
Court Address
vs.
Defendant
Case No.
, MARYLAND
Street Address
Street Address
City, State, Zip
Telephone
City, State, Zip
FINANCIAL STATEMENT OF (General)
(Md Rule 9-203(a))
Name
Telephone
MDEC counties only: You must file a Notice Regarding Restricted Information Pursuant to Rule 20-201.1 (form MDJ-008) with this submission.
Children
Age
ITEM
A. PRIMARY RESIDENCE Mortgage Insurance (homeowners) Rent/Ground Rent Taxes Gas & Electric Electric Only Heat (oil) Telephone Trash Removal Water Bill Cell Phone/Pager Repairs
CC-DR-031 (Rev. 12/2020)
MONTHLY EXPENSES SELF
CHILDREN TOTAL
Page 1 of 6
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Lawn & Yard Care (snow removal) Replacement Furnishings/Appliances Condominium Fee (not included elsewhere) Painting/Wallpapering Carpet Cleaning Domestic Assistance/Housekeeper Pool Other: SUB TOTAL
B. SECONDARY RESIDENCE (i.e. Summer Home/Rental) Mortgage Insurance (homeowners) Rent/Ground Rent Taxes Gas & Electric Electric Only Heat (oil) Telephone Trash Removal Water Bill Cell Phone/Pager Repairs Lawn & Yard Care (snow removal) Replacement Furnishings/Appliances Condominium Fee (not included elsewhere) Painting/Wallpapering Carpet Cleaning Domestic Assistance/Housekeeper Pool Other: SUB TOTAL
Case No.
$ 0.00
$ 0.00
$ 0.00
$ 0.00
C. OTHER HOUSEHOLD NECESSITIES Food
CC-DR-031 (Rev. 12/2020)
Page 2 of 6
$ 0.00
$ 0.00 FISTA
Drug Store Items Household Supplies Other: SUB TOTAL
Case No.
$ 0.00
$ 0.00
D. MEDICAL/DENTAL Health Insurance Therapist/Counselor Extraordinary Medical Dental/Orthodontia Ophthalmologist/Glasses Other: SUB TOTAL
$ 0.00
$ 0.00
E. SCHOOL EXPENSES Tuition/Books School lunch Extracurricular activities Clothing/Uniforms Room & Board Daycare/Nursery School Other: SUB TOTAL
$ 0.00
$ 0.00
F. RECREATION & ENTERTAINMENT
Vacations
Videos/Theater
Dining Out
Cable TV/Internet
Allowance
Camp
Memberships
Dance/Music Lessons etc.
Horseback Riding
Other:
SUB TOTAL
CC-DR-031 (Rev. 12/2020)
$ 0.00
Page 3 of 6
$ 0.00
$ 0.00 $ 0.00 $ 0.00
$ 0.00 FISTA
G. TRANSPORTATION EXPENSE Automobile Payment Automobile Repairs Maintenance/Tags/Tires/etc. Oil/Gas Automobile Insurance Parking Fees Bus/Taxi Other: SUB TOTAL
H. GIFTS Holiday Gifts Birthdays Gifts to Others Charities SUB TOTAL
I. CLOTHING Purchasing Laundry Alterations/Dry Cleaning Other: SUB TOTAL
J. INCIDENTALS Books & Magazines Newspapers Stamps/Stationery Banking Expense Other: SUB TOTAL
Case No.
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
CC-DR-031 (Rev. 12/2020)
Page 4 of 6
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Case No.
K. MISCELLANEOUS/OTHER Alimony/Child Support (from a previous Order) Religious Contributions Hairdresser/Haircuts Manicure/Pedicure Pets/Boarding Life Insurance Other: SUB TOTAL
$ 0.00
$ 0.00
$ 0.00
TOTAL MONTHLY EXPENSES:
$ 0.00
$ 0.00
Number of dependent children, including children who have not attained the age of 19 years, are not
married or self-supporting, and are enrolled in secondary school:
INCOME STATEMENT
GROSS MONTHLY WAGES: Deductions: Federal State Medicare F.I.C.A. Retirement Total Deductions: NET INCOME FROM WAGES: OTHER GROSS INCOME: (alimony, part-time job, rentals etc.) Deductions: a. b. c. Total deductions from Other income: NET OTHER INCOME TOTAL MONTHLY INCOME
$ 0.00 $ 0.00
$ 0.00
$ 0.00 $ 0.00
CC-DR-031 (Rev. 12/2020)
Page 5 of 6
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ASSETS: Real Estate Furniture (in the marital house) Bank Accounts/Savings U.S. Bonds Stocks/Investments Personal Property Jewelry Automobiles Boats Other: TOTAL ASSETS:
Case No. ASSETS & LIABILITIES
$ 0.00
LIABILITIES:
Mortgage
Automobiles
Notes payable to relatives
Bank Loans
Accrued Taxes
Balance of Credit Card Accounts
a.
b.
c.
Other:
TOTAL LIABILITIES
$ 0.00
TOTAL NET WORTH:
$ 0.00
SUMMARY:
TOTAL INCOME:
$ 0.00
TOTAL EXPENSES:
EXCESS OR DEFICIT:
$ 0.00
I solemnly affirm under the penalties of perjury that the contents of this document, Monthly Expense List, and Assets and Liabilities Statement are true to the best of my knowledge, information, and belief.
Date
Signature
CC-DR-031 (Rev. 12/2020)
Page 6 of 6
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