Form 6-1-2 (Ag) - Income & Expense Form - Family Maintenance Enforcement Program Page 2

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FMEP Case #:
______________________
PART 4: MONTHLY INCOME
Net Income
$ _________________
(provide copies of last 3 pay stubs)
Overtime pay, commissions, bonuses or holiday pay
$ _________________
(calculate total received for the year and divide by 12)
Self-Employed Business Income
$ _________________
(provide copies of last 3 bank statements)
Pension/Disability Income
$ _________________
(provide copies of last 3 income stubs)
Other Income (specify) _______________________________
$ _________________
Rental Income
$ _________________
Child Tax Credit/Child or Spousal Support Income
$ _________________
Net Income of Spouse or Common-law Spouse
$ _________________
TOTAL MONTHLY INCOME
$ ________________
PART 5: MONTHLY EXPENSES
Rent
Mortgage (include property taxes)
$ _________________
Insurance – Life/House or Tenant
$ _________________
Utilities - Heat/Hydro/Water
$ _________________
Cable/Internet
$ _________________
Telephone/Cellular
$ _________________
Child and/or Spousal Support Payment
$ _________________
Food
$ _________________
Restaurant Meals/Entertainment
$ _________________
Clothing
$ _________________
Dental/Medical/Prescriptions (not covered by a medical plan)
$ _________________
Vehicle - Gas/Oil/Insurance
Number of vehicles _________
$ _________________
Other (specify) _____________________________________
$ _________________
Other (specify) _____________________________________
$ _________________
Total Monthly Debt Payment (from Part 3: Debts)
$ _________________
TOTAL MONTHLY EXPENSES
$ ________________
The information on this form is collected pursuant to the Family Maintenance Enforcement Act for the purpose of monitoring and enforcing
your maintenance order or agreement. To obtain information about privacy protection, contact the FMEP office handling your case.
6-1-2 (AG)
Aug 2007

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