CASE NUMBER
STATE OF HAWAI‘I
INCOME AND EXPENSE STATEMENT
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FAMILY COURT
Plaintiff
Defendant
FC-
NO.
SECOND CIRCUIT
This document is prepared by
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Plaintiff
Defendant
Atty. for Plaintiff
Atty. for Defendant
PLAINTIFF
_________________________________________________
(Full Name)
Name
_________________________________________________
VS.
_________________________________________________
Address
_________________________________________________
City, State, Zip
DEFENDANT
_________________________________________________
(Full Name)
Phone
Occupation: _________________________________________________________________________________
Job title
Employer: __________________________________________________________________________________
Address: ___________________________________________________________________________________
Length of service: _____________ months/years.
Income Tax Withholding based on: ________ dependents.
INCOME
Gross income. Paid:
monthly,
2 times per month,
every 2 weeks,
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/401K ...................................
$ ____________
Credit Union ..........................................
$ ____________
Direct Deposit .......................................
$ ____________
Income Assignments..............................
$ ____________
Support Payments ..................................
$ ____________
Medical Insurance .................................
$ ____________
b) Take home per pay period ....... $ ___________
Per month ........ $ _____________
Other regular monthly income, (rental income, 2nd 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 ...............................
$ ____________
Total Monthly Income (Add per month income from lines a and c above) $ _____________
Reprographics (01/12)
2F-P-409
INCOME & EXPENSE STATEMENT
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