Form Csf 010100 - Uniform Income Statement Form
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UNIFORM INCOME STATEMENT
Lawyer's Name:
Phone:
Please print when completing all of the following information.
Case Number
Date
Name
Mailing Address and Physical Address
City
State
Zip
Home Telephone Number
IF YOU ARE CURRENTLY EMPLOYED:
a) Are you working full time?
[ ] Yes
[ ] No
If not, how many hours per week do you work?
b)
Name, address & phone number of employer:
c) What is the amount of your gross monthly income? $
d) ATTACH A COPY OF YOUR MOST RECENT PAY STUB
IF YOU ARE UNEMPLOYED:
a) What type of work have you done in the past?
b) What kind of job skills do you have?
c) Why did you leave your last job?
d) Are you receiving workers' compensation or unemployment benefits?
[ ] Yes
[ ] No
e) If yes, list the monthly amount of benefits and source:
Source:
Amount: $
IF YOU ARE SELF-EMPLOYED:
a)
Name, address & phone number of your business:
b) List the annual gross receipts:
c) List costs of goods sold minus ordinary expenses required for business operations: $
d) ATTACH A COPY OF THE MOST CURRENT IRS TAX RETURN FILED (PERSONAL AND BUSINESS, INCLUDING
ALL SCHEDULES.)
OTHER INCOME: (Commissions, advances, bonuses, dividends, severance pay, pensions, interest, trust income, return on capital,
annuities, social security benefits, including those paid on behalf of a child, benefits from disability insurance, gifts, prizes, alimony, food
stamps, public assistance, supplemental security income)
Source:
Amount: $
Source:
Amount: $
Source:
Amount: $
Bank Account #:
Bank:
Savings Account #:
Bank:
Page 1 of 3 - UNIFORM INCOME STATEMENT
CSF 01 0100 (Rev. 07/19/07)
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Parent category: Financial