Income And Expense Statement - Family Court First Circuit

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CASE NUMBER
STATE OF HAWAI‘I
INCOME AND EXPENSE STATEMENT
FAMILY COURT
Plaintiff
Defendant
FIRST CIRCUIT
FC-D No.
This document is prepared by:
G
G
G
G
Defendant
Plaintiff
Atty for Plaintiff
Atty for Defendant
(Full Name)
PLAINTIFF,
Name
Address
v.
City, State, Zip Code
(Full Name)
Telephone No.
DEFENDANT.
Employer:
Occupation (Job Title):
Address:
Length of Service:
months/years. Income Tax Withholding based on:
dependents.
INCOME
G
G
G
G
G
Gross income paid:
monthly,
2 times per month,
every 2weeks,
weekly,
or other:
Gross per pay period.......................... $
Per month....$
Payroll deductions per pay period:
Fed. income tax............................. $
State income tax............................ $
FICA (Social Security)................... $
Union dues..................................... $
a) Net per pay period........................ $
Per month....$
Other:
Retirement/401 K........................... $
Credit Union................................... $
Direct Deposit................................ $
Income Assignments..................... $
Support Payments......................... $
Medical Insurance......................... $
b) Take home per pay period............. $
Per month.... $
nd
Other regular monthly income (rental income, 2
job, interest, child support, welfare,
food stamps, and any other source).
Gross monthly receipt.................... $
Taxes
... $
paid IRS and State on above
c) Total other income net.................. $
Per month.... $
Total Monthly Income (Add per month from lines a and c above).... $
COURT USE ONLY
PAGE 1 OF 3 PAGES
FC Adm 1/6/14
INCOME & EXPENSE STATEMENT
RESET FORM

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