Declaration Of Income And Expenses Page 3

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Debt:
9 I owe the following debts:
To whom owed
Amount
To whom owed
Amount
$________________
$_______________
$________________
$_______________
$________________
$_______________
Expenses:
9 In an average month, I spend money for the following items:
Amount
Amount
Amount
Food
$__________
Gas
$__________
Child
$__________
support
Clothing
$__________
Water
$__________
Cost of housing
$__________
Telephone
$__________
Education
$__________
expense
Transportation
$__________
Uninsured
$__________
Other (list)
$__________
medical
expenses
Electricity
$__________
Health
$__________
Other (list)
$__________
insurance
Being sworn, I affirm that:
•
I have read this Declaration of Income and Expenses and the statements in it are true and
correct to the best of my knowledge.
•
I know that an intentionally false statement could subject me to prosecution for perjury.
_____________________________
Petitioner
3
May 6, 2006

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