Form 12510 - Questionnaire For Requesting Spouse Page 2
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46. During the year(s) in question did you have your own separate bank account(s)?
[
] Yes
[
] No
If yes, indicate the type of account(s).
[
] Checking
[
] Savings
[
] Other
6a. What funds were deposited to the account(s)?
6b. What bills were paid out of the account(s)?
7.
During the year(s) in question did you and your (former) spouse have any joint bank account(s)?
[
] Yes
[
] No
If yes, indicate the type of account(s).
[
] Checking
[
] Savings
[
] Other
7a. What access did you have to the account(s)? (For example, were you able to make deposits, write checks and withdraw funds?)
7b. What funds were deposited to the account(s)?
7c. Who made the deposits?
7d. What bills were paid out of the account(s)?
7e. Who wrote the checks?
[
] Yes
[
] No
7f. Did you review the monthly bank statements?
[
] Yes
[
] No
7g. Did you balance the checkbook to the bank statements?
[
] Yes
[
] No
8.
Did you pick up and/or open the household mail?
9.
Please complete the following for the year(s) you are requesting relief:
Average Monthly Household Income and Expenses
Income
Amount
Expenses
Amount
Wages
Rent or Mortgage
Pensions
Food
Unemployment
Utilities
Social Security
Telephone
State, Local and Federal Support
Auto Payments
Alimony
Auto Insurance
Child Support
Auto - Gasoline & Repairs
Self-Employment
Medical - Insurance & Other
Rental Income
Life Insurance
Interest and Dividends
Clothing
Other(Gov't Assistance, Food Stamps, etc)
Child Care
Public Transportation
Other (please explain)
Less deductions for W/H, Medicare, state
(
)
Taxes, etc
TOTAL
TOTAL
10.
Were you abused by your (former) spouse during year(s) in question? Please describe the nature and extent of the abuse.
Since we do not request information of this nature from third parties, it is your responsibility to provide dates and any
documentation such as police reports, doctor's statements or an affidavit from someone aware of the abuse.
12510
Form
(Rev. 3-2005)
Page 2 of 4
Catalog Number 28752D
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Parent category: Financial