General Testimony Page 10
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30GENERAL TESTIMONY, PAGE 8
Initiating IV-D Case No.
Petitioner
Current Spouse/Partner
Obligor's Dependent(s)
5. Adjusted Net Monthly
$_______________
$________________
$________________
(lines "3" minus lines "4a through 4d")
6. Other Deductions
a) Savings
$_______________
$________________
$________________
b) Loan Repayment
$_______________
$________________
$________________
c) Mandatory Retirement
$_______________
$________________
$________________
d) Non-mandatory Retirement
$_______________
$________________
$________________
e) Medical Insurance
$_______________
$________________
$________________
f) Union Dues
$_______________
$________________
$________________
g) Other (specify)
$_______________
$________________
$________________
7. Net Monthly Income
$_______________
$________________
$________________
(line 5 minus lines "6a through 6g")
8. Gross Income Prior Year
$_______________
$________________
$________________
Attach three most recent paystubs from each current employer for all parties shown.
B. Monthly Expenses:
Petitioner
Obligor's Dependent(s)
1) Rent/Mortgage
$________________
$________________
2) Homeowners/Renters Insurance
$________________
$________________
3) Home Maintenance & Repair
$________________
$________________
4) Heat
$________________
$________________
5) Electricity/Gas
$________________
$________________
6) Telephone
$________________
$________________
7) Water/Sewer
$________________
$________________
8) Food
$________________
$________________
9) Laundry/Cleaning
$________________
$________________
10) Clothing
$________________
$________________
11) Life Insurance
$________________
$________________
12) Medical Insurance
$________________
$________________
13) Uninsured Extraordinary Medical (attach documentation)
$________________
$________________
14) Other Uninsured Health-Related Expenses
$________________
$________________
15) Auto Payment
$________________
$________________
16) Auto Insurance
$________________
$________________
17) Auto Expenses
$________________
$________________
18) Other Transportation
$________________
$________________
19) Child Care
$________________
$________________
Provider:_________________________________________
Frequency:________________________________________
20) Support Payments, actual amount paid
$________________
$________________
21) Other; Explain:__________________________________
$________________
$________________
Total Monthly Expenses (lines 1 through 21)
$________________
$________________
General Testimony
Page 8 of 10
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