FINANCIAL INFORMATION SHEET
CAUSE
NO..............................................................................................
DISTRICT COURT
PETITIONER..................................................................................................
RESPONDENT
ATTORNEY FOR PETITIONER.....................................
ATTORNEY FOR RESPONDENT
DATE OF MARRIAGE:_______________ DATE OF PRIOR
ORDER:_________________
AGES OF CHILDREN OF MARRIAGE: ( ) ( ) ( ) ( )
MONTHLY EXPENSES:
HOUSING:
House payments/rent ......................................................................................$_____________
Utilities [gas, water, elec., phone] ....................................................................$_____________
Maintenance, repair .........................................................................................$_____________
TRANSPORTATION:
Car payment ...................................................................................................$_____________
Car Insurance..................................................................................................$_____________
Gasoline, Oil, Maintenance, etc.
Parking, other
INSURANCE:
Life
Other:
GROCERIES:................................................................................................$_____________
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
Other
MISCELLANEOUS:
OTHER DEBTS:
Attorney's Fees
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, etc.]
I certify that the above answers to the questions as listed
are true and correct.
Signature__________________________________________________
05/22/00 http://www.raggiolaw.com/budget.htm