Form #4 - Financial Affidavit - Pitt County General Court Of Justice Page 3

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Form #4
Part 2
Individual Monthly Expenses
Date of Separation
Current
Date:
Date:
Expense
Self
Children
Total
Self
Children
Total
Medical Insurance
premium
Dental/Vision
Insurance premium
Other insurance
premiums
(life, disability, etc.)
Uninsured Medical
expenses
(co-pays,
deductibles)
Uninsured Dental &
Orthodontic expense
Uninsured
Prescription and OTC
drugs & medication
Other uninsured
medical expenses
(e.g. optical)
Gifts
(Holidays, birthdays)
Church donations
Other charitable
contributions
Entertainment
& Recreation
Club dues &
assessments
Dues
Annual vacation
Eating Out
Clothing, accessories
Laundry, Dry
Cleaning
Personal Upkeep
(barber, hair stylist)
Newspapers,
Magazines
Retirement &
investment
Savings
Professional fees
(CPA, etc.)
3
Pitt County Family Court Domestic Forms, 2017

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