|
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 $
|
|
Withholding/FICA |
$ __________ |
|
|
Insurance |
$ __________ |
|
|
Retirement |
$ __________ |
|
|
Other |
$ __________ |
|
|
Total deductions |
$ __________ |
|
|
[Name of party A]’s net income from primary employment per month |
$ __________ |
|
|
[Name of party A]’s average income from other sources per month |
$ __________ |
|
|
[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 $
|
|
Withholding/FICA |
$ __________ |
|
|
Insurance |
$ __________ |
|
|
Retirement |
$ __________ |
|
|
Other |
$ __________ |
|
|
Total deductions |
$ __________ |
|
|
[Name of party B]’s net income from primary employment per month |
$ __________ |
|
|
[Name of party B]’s average income from other sources per month |
$ __________ |
|
|
[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:
|
|
House payment or rent (include second mortgage, insurance, taxes, condominium assessments) |
$ __________ |
|
|
Utilities including telephone |
$ __________ |
|
|
Food including school lunches |
$ __________ |
|
|
Child care |
$ __________ |
|
|
Car payments and auto insurance |
$ __________ |
|
|
Gasoline, oil, parking, bus fares, tolls, repairs |
$ __________ |
|
|
Attorney’s fees |
$ __________ |
|
|
Health and life insurance premiums (exclude company-paid insurance) |
$ __________ |
|
|
Uninsured medical and drug expenses |
$ __________ |
|
|
Uninsured dental and orthodontic expenses |
$ __________ |
|
|
Uninsured mental health care expenses |
$ __________ |
|
|
Clothing and laundry |
$ __________ |
|
|
Personal (entertainment, adult education, etc.) |
$ __________ |
|
|
Minimum monthly debt service (see item 9. below) |
$ __________ |
|
|
Total |
$ __________ |
9.Debts (exclude house mortgage and car payments):
|
|
Creditor |
Balance of Debt |
Minimum Monthly |
|---|---|---|---|
|
|
____________________ |
$ __________________ |
$ __________________ |
|
|
____________________ |
$ __________________ |
$ __________________ |
|
|
____________________ |
$ __________________ |
$ __________________ |
|
|
____________________ |
$ __________________ |
$ __________________ |
|
|
____________________ |
$ __________________ |
$ __________________ |
10.Funds and assets readily convertible into cash in control of [name of party A]:
|
|
Accounts in financial institutions (banks, savings and loans, credit unions, certificates of deposit) |
$ __________ |
|
|
Stocks and bonds |
$ __________ |
11.Funds and assets readily convertible into cash in control of [name of party B]:
|
|
Accounts in financial institutions (banks, savings and loans, credit unions, certificates of deposit) |
$ __________ |
|
|
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:
|
|
Temporary child support |
$ __________ |
|
|
Temporary alimony |
$ __________ |
|
|
Total |
$ __________ |
|
Or |
15.Amount I want to pay as:
|
|
Temporary child support |
$ __________ |
|
|
Temporary alimony |
$ __________ |
|
|
Total |
$ __________ |
SIGNED on ________________________________.
[[Name of party A]/[Name of party B]]
|
Prepare in triplicate. |