Form A - Income & Expense Affidavit

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Form A
INCOME & EXPENSE AFFIDAVIT
__________________________________
NO: __________________ DIV. ______
(
)
PETITIONER
THE FAMILY COURT
VERSUS
PARISH OF EAST BATON ROUGE
__________________________________
STATE OF LOUISIANA
(
)
DEFENDANT
PARISH OF ___________________________________
STATE OF LOUISIANA
BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in this state and
parish, personally appeared ___________________________________, who after being duly sworn,
declared that the following figures and amounts are accurate to the best of his/her knowledge:
I. INCOME
Gross Monthly Income
Source
Amount
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
Total Gross Monthly Income
$________________
Itemized Payroll Deductions
Source
Amount
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
Total Monthly Deductions
$________________
NET MONTHLY INCOME
$________________
II. LIVING EXPENSES
Type
Amount for Spouse/Parent
Amount for Chilld(ren)
Rent/Mortgage Note
$________________
$________________
Food
$________________
$________________
Automobile Note
$________________
$________________
Clothing
$________________
$________________
Transportation (Fuel Costs)
$________________
$________________
Medical
$________________
$________________
Dental
$________________
$________________
Prescriptions
$________________
$________________
Household
$________________
$________________
Laundry
$________________
$________________
Personal Grooming
$________________
$________________
Electricity
$________________
$________________
THE FAMILY COURT
FORM A, p. 1 of 2
REVISED: NOV 2013

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