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Include the following notice if a minor is named in the caption or if the statement contains other unredacted sensitive data. See § 6 of the Introduction in volume 1 of this manual concerning protection of sensitive data in filed documents. |
NOTICE: THIS DOCUMENT CONTAINS SENSITIVE DATA
[Caption. See § 3 of the Introduction in volume 1 of this manual.]
Financial Information Statement
[for Hearings on Temporary Orders and Final Divorce]
This statement is submitted by [[name of party A]/[name of party B]].
1.Date of marriage:
2.Date of separation:
3.Age[s] of child[ren] of this marriage:
4.[Name of party A]’s occupation:
5.[Name of party A]’s gross earnings from primary employment per month $
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Withholding/FICA |
$ __________ |
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Insurance |
$ __________ |
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Retirement |
$ __________ |
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Other |
$ __________ |
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Total deductions |
$ __________ |
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[Name of party A]’s net income from primary employment per month |
$ __________ |
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[Name of party A]’s average income from other sources per month |
$ __________ |
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[Name of party A]’s net income per month |
$ __________ |
(Please attach applicable 1040s, W-2s, or most recent pay stub.)
6.[Name of party B]’s occupation:
7.[Name of party B]’s gross earnings from primary employment per month $
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Withholding/FICA |
$ __________ |
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Insurance |
$ __________ |
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Retirement |
$ __________ |
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Other |
$ __________ |
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Total deductions |
$ __________ |
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[Name of party B]’s net income from primary employment per month |
$ __________ |
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[Name of party B]’s average income from other sources per month |
$ __________ |
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[Name of party B]’s net income per month |
$ __________ |
(Please attach applicable 1040s, W-2s, or most recent pay stub.)
8.Necessary monthly living expenses:
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House payment or rent (include second mortgage, insurance, taxes, condominium assessments) |
$ __________ |
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Utilities including telephone |
$ __________ |
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Food including school lunches |
$ __________ |
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Child care |
$ __________ |
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Car payments and auto insurance |
$ __________ |
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Gasoline, oil, parking, bus fares, tolls, repairs |
$ __________ |
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Attorney’s fees |
$ __________ |
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Health and life insurance premiums (exclude company-paid insurance) |
$ __________ |
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Uninsured medical and drug expenses |
$ __________ |
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Uninsured dental and orthodontic expenses |
$ __________ |
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Uninsured mental health care expenses |
$ __________ |
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Clothing and laundry |
$ __________ |
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Personal (entertainment, adult education, etc.) |
$ __________ |
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Minimum monthly debt service (see item 9. below) |
$ __________ |
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Total |
$ __________ |
9.Debts (exclude house mortgage and car payments):
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Creditor |
Balance of Debt |
Minimum Monthly |
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____________________ |
$ __________________ |
$ __________________ |
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____________________ |
$ __________________ |
$ __________________ |
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____________________ |
$ __________________ |
$ __________________ |
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____________________ |
$ __________________ |
$ __________________ |
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____________________ |
$ __________________ |
$ __________________ |
10.Funds and assets readily convertible into cash in control of [name of party A]:
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Accounts in financial institutions (banks, savings and loans, credit unions, certificates of deposit) |
$ __________ |
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Stocks and bonds |
$ __________ |
11.Funds and assets readily convertible into cash in control of [name of party B]:
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Accounts in financial institutions (banks, savings and loans, credit unions, certificates of deposit) |
$ __________ |
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Stocks and bonds |
$ __________ |
12.Child[ren] presently residing with:
13.Number of child[ren] not before the Court entitled to support from [[name of party A]/[name of party B]]:
14.Amount I want to receive as:
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Temporary child support |
$ __________ |
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Temporary spousal support |
$ __________ |
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Total |
$ __________ |
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Or |
15.Amount I want to pay as:
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Temporary child support |
$ __________ |
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Temporary spousal support |
$ __________ |
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Total |
$ __________ |
SIGNED on ________________________________.
[[Name of party A]/[Name of party B]]
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Prepare in triplicate. |