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SAMPLE FINANCIAL INFORMATION SHEET CAUSE NO: __________________________________________ DISTRICT COURT COUNT _____________________________ RESPONDENT ______________________________________ ATTORNEY FOR PETITIONER ________________________________________________ ATTORNEY FOR RESPONDENT ________________________________________________ DATE OF MARRIAGE: ________________________________________________ DATE OF PRIOR ORDER: ______________________________________________ NAMES and AGES OF CHILDREN OF MARRIAGE: 1._________________________________________________________________________________ 2._________________________________________________________________________________ 3._________________________________________________________________________________ 4._________________________________________________________________________________ MONTHLY EXPENSES: HOUSING: House payments/rent ......................................................................................$_____________ Utilities [gas, water, elec., phone] ....................................................................$_____________ Maintenance, repair .........................................................................................$_____________ Taxes and Insurance.........................................................................................$_____________ Internet Expense.........................................................................................$_____________ Cable Television.........................................................................................$_____________ Pool.........................................................................................$_____________ Yard.........................................................................................$_____________ TRANSPORTATION: Car Numbe One payment ...............................................................................$_____________ Car Insurance..................................................................................................$_____________ Gasoline, Oil, Maintenance, etc. .....................................................................$_____________ Parking and tolls .........................................................................................$_____________ INSURANCE: Life .........................................................................................$_____________ Health .........................................................................................$_____________ (parties included) Dental .........................................................................................$_____________ GROCERIES:................................................................................................$_____________ PERSONAL: Work Expenses: Lunches Dues, fees Medical (not covered by insurance) Doctors/Dentists Drugs Clothing Cleaning, Laundry Grooming [haircuts, etc.] Entertainment [cable television] Current child support Other CHILDREN: Child Care: School: Tuition, fees Lunches Supplies Medical [not covered by insurance] Doctors/Dentists Drugs Clothing Cleaning, Laundry Grooming [haircuts, etc.] Entertainment, activities Camp Other MISCELLANEOUS: MONTHLY OUTSTANDING DEBTS: ITEMIZE CONSUMER DEBT:
TOTAL MONTHLY EXPENSES: ...................................................$________________ MONTHLY INCOME [Pay period - ( ) Monthly ( ) Weekly ( ) Twice a Month] GROSS MONTHLY INCOME: [attach 3 pay stubs) DEDUCTIONS: Federal withholding tax $ FICA Retirement Health, hospitalization, life ins. Other: Business expenses, including malpractice NET INCOME:........................................................................................$_______________ CURRENT CHILD SUPPORT: OTHER INCOME: Source TOTAL MONTHLY INCOME:..............................................................$_______________ LIQUID ASSETS: [Cash, Bearer Bonds, Money Orders, Uncashed Checks.] I certify that the above answers to the questions as listed are true
and correct. Signature__________________________________________________
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