B. MONTHLY DEBT PAYMENTS
Do not list expenses previously listed in Section A (Monthly Expenses). Attach additional pages if needed.
TO WHOM PAID
PURPOSE/SECURITY
MONTHLY
TOTAL
(ALSO INDICATE NAME ACCOUNT IS
(IF CAR LOAN, STATE MODEL
PAYMENT
BALANCE
IN OR JOINT ACCOUNT)
& WHO DRIVES IT)
DUE
$
$
$
$
$
$
$
$
$
MONTHLY DEBT PAYMENTS
(III)
T
OTAL…………………………………………………
GRAND TOTAL MONTHLY
$
EXPENSES…………………………………………………………………
V.
HEALTH INSURANCE
GROUP HEALTH INSURANCE COVERAGE AVAILABLE FOR DEPENDENT CHILDREN
(This section to be filled in ONLY when there are dependent children of the parties.)
PLAINTIFF/PETITIONER (1)
DEFENDANT/PETITIONER (2)
YES / NO
Available through employment
YES / NO
YES / NO
Other Group Plan
YES / NO
____________________________________ Insurance Company Name
____________________________________
____________________________________
____________________________________
____________________________________
Address
____________________________________
Policy Number
____________________________________
____________________________________
$
per year / month (individual)
Employee Cost
$
per year / month (individual)
$
per year / month (family)
(Indicate "0" if no cost to party)
$
per year / month (family)
or
INDIVIDUAL PLAN
CHECK IF CHILDREN ARE CURRENTLY ENROLLED:
FAMILY PLAN
Affiant states that the information contained herein and attached hereto, is complete and accurate to the best of his/her
information, knowledge or belief under penalty of law.
_______________________________________________
________________________________________________
Attorney for Plaintiff/Defendant/Petitioner
Affiant Plaintiff/Petitioner (1)
Defendant/Petitioner (2)
Sworn to and subscribed in my presence this _____________ day of ____________________________________,___________.
__________________________________________________
Notary Public
My commission expires _____________________________
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