FINANCIAL INFORMATION STATEMENT
CLIENT: CAUSE NUMBER:
FINANCIAL INFORMATION STATEMENT
MONTHLY INCOME
Gross Income:
$
Withholding
$
FICA (Social Security)
$
Mandatory Retirement
$
Voluntary Retirement (401K)
$
Deferred Compensation
$
Life Insurance
$
Credit Union (savings)
$
Credit Union (loan payment)
$
Health Insurance
$
Other Deductions: Union Dues
$
Federal Med/EE
$
Income After Deductions:
$
Other Income (itemize below :
_______________________________________________________
$
_______________________________________________________
$
_______________________________________________________
$
TOTAL MONTHLY INCOME:
$
MONTHLY EXPENSES
Rent or Mortgage Payment ........................................................................................ $
Real Property Taxes (if not included in mortgage payment).................................. $
Homeowner's insurance (if not included in mortgage payment) ......................... $
Renter's or fire insurance ............................................................................................. $
Maintenance or residence (repairs, yard work, etc.) .............................................. $
Utilities (gas, water, electric, garbage, sewer, etc.) ................................................ $
Telephone ..................................................................................................................... $
Groceries ....................................................................................................................... $
Dining out ...................................................................................................................... $
School lunches.............................................................................................................. $
Uninsured doctor expenses ......................................................................................... $
Uninsured prescription and pharmaceutical expenses........................................... $
Uninsured routine dental care .................................................................................... $
Uninsured orthodontal care ........................................................................................ $
Health and hospitalization insurance (if not paid by employer or deducted
$
from wages) ..................................................................................................................
Life insurance (if not paid by employer or deducted from wages)....................... $
Clothing purchases ...................................................................................................... $
Laundry and dry cleaning .......................................................................................... $
Vehicle payment.......................................................................................................... $
Gas and oil for vehicle................................................................................................. $
Vehicle repair and maintenance .............................................................................. $
Vehicle insurance......................................................................................................... $
Parking fees ................................................................................................................... $
School tuition ................................................................................................................ $
School supplies ............................................................................................................. $ Children's extracurricular activities ............................................................................. $
Childcare while at work............................................................................................... $
Childcare for other times............................................................................................. $ Entertainment ............................................................................................................... $ Hairstyling, barber......................................................................................................... $ Contributions ................................................................................................................. $ Dues ............................................................................................................................... $ Subscriptions.................................................................................................................. $ Prior obligations for child support or alimony ............................................................ $
SUBTOTAL: $
Other Creditors (itemize below)
NAME
PURPOSE
BALANCE
MONTHLY PAYMENT
TOTAL MONTHLY EXPENSES
SUBTOTAL: $ $
Community Property = CP Wife's Separate Property = WSP Husband's Separate Property = HSP
PROPERTY ITEM NUMBER
PROPERTY DESCRIPTION
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
PETITIONER VALUE CHARACTER
RESPONDENT
VALUE
CHARACTER
COURT'S NOTES
Community Debt = CD Wife's Separate Debt = WSD Husband's Separate Debt = HSD
DEBT ITEM NUMBER
DEBT DESCRIPTION
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.
PETITIONER AMOUNT CHARACTER
RESPONDENT AMOUNT CHARACTER
COURT'S NOTES
................
................
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