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 2 years IRS returns and 2
mast recent payroll stubs and if none, provide W-2 forms.
FINANCIAL
INFORMATION STATEMENT
NO. _________________________________ _________ District Court
_____________________________________ ____________________________________
PETITIONER RESPONDENT
_____________________________________ ____________________________________
ATTORNEY ATTORNEY
1. Date of Marriage: ___________________ Date of Separation: ___________________
2. Ages of Children: (_______) (_______) (_______) (_______) (_______) (_______)
3. GROSS MONTHLY RESOURCES:
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 Camp. ______________________ ________________________
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 IS PAID EVERY: [] week [] two weeks [] bimonthly [] monthly
HUSBAND IS PAID EVERY: [] week [] two weeks [] bimonthly [] monthly
Date Next Check is Received: WIFE__________________ HUSBAND ___________________
7. QUICK ASSETS: WIFE HUSBAND
Cash/Undeposited Checks $_____________________ ________________________
Financial Institutions ______________________ ________________________
Stocks/Bonds ______________________ ________________________
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/OiI/Parkillg ____________ 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
__________________________ $____________ $____________________
__________________________ _____________ _____________________
__________________________ _____________ _____________________
__________________________ _____________ _____________________
__________________________ _____________ _____________________
__________________________ _____________ _____________________
TOTAL MONTHLY: $_____________ + $________________
10. GRAND TOTAL MONTHLY EXPENSES: $_____________________
11. (ANSWER ONLY IF YOU ANTICIPATE RECEIVING SUPPORTI) 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
support and alimony $________________ $_________________
(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 lBb $_________________ $_________________
DATE: ___________________ __________________________________________ WIFE’S SIGNATURE
DATE: ___________________ __________________________________________
HUSBAND’S SIGNATURE