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