Judgment And Decree For Marriage Dissolution With Children Page 12
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43Employer’s Street Address
City
State
Zip Code
st
nd
Questions about Current Jobs
1
Job
2
Job
Is Petitioner A paid by the hour or
hourly
salary
hourly
salary
salaried?
What is the average number of
hours Petitioner A works per
________________hours
________________hours
week?
How much overtime pay does
Petitioner A receive per week on
$_____________________
$____________________
average?
Does
Petitioner
A
receive
If Yes, how much was received
If Yes, how much was
in bonuses last year?
received in bonuses last year?
bonuses?
$_____________
$_____________
st
Yes
No 1
Job
How much does Petitioner A
How much does Petitioner A
expect to receive this year?
expect to receive this year?
nd
Yes
No 2
Job
$___________
$___________
Petitioner A’s Income
21.
Source of Income
Amount Per Month (or zero) before deductions/taxes
Self Employment Income
$______________ per month
Self Employment income means gross receipts minus costs of goods sold
minus ordinary and necessary business expenses.
Job with __________________________
$______________ per month
Monthly income from a job = Hourly wage x Hours worked per week x 4.33 (weeks per month)
Second Job with _____________________
$______________ per month
Third Job with ______________________
$______________ per month
Commissions from all jobs
$______________ per month
Divide the total amount you expect this year by 12 to get a monthly average
Unemployment benefits
$______________ per month
Social Security Retirement, Survivors or Disability
Income (RSDI) (do not include SSI)
$______________ per month
Investment and Rental Income
$______________ per month
Annuity payments
$______________ per month
DIV1702
State
ENG
Rev 09/13
Page 12 of 43
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