Appendix V - Family Part Case Information Statement Form Page 4

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3. GROSS INCOME NET OF TAXES $
$
4. OTHER DEDUCTIONS
If mandatory, check box
a.
Hospitalization/Medical Insurance
a.
$
b.
Life Insurance
b.
$
c.
Union Dues
c.
$
d.
401(k) Plans
d.
$
e.
Pension/Retirement Plans
e.
$
f.
Other Plans - specify
f.
$
g.
Charity
g.
$
h.
Wage Execution
h.
$
i.
Medical Reimbursement (flex fund)
i.
$
j.
Other:
j.
$
TOTAL
$
5. NET YEAR-TO-DATE EARNED INCOME:
$
NET AVERAGE EARNED INCOME PER MONTH:
$
NET AVERAGE EARNED INCOME PER WEEK
$
4. Your Year-to-Date Gross Unearned Income From All Sources
(including, but not limited to, income from unemployment, disability and/or social security payments, interest, dividends,
rental income and any other miscellaneous unearned income)
Source
How often paid
Year to date amount
$
$
$
$
$
$
$
$
$
TOTAL GROSS UNEARNED INCOME YEAR TO DATE
$
5. Additional Information:
1.
How often are you paid?
2.
What is your annual salary?
$
3.
Have you received any raises in the current year?
Yes
No
If yes, provide the date and the gross/net amount.
4.
Do you receive bonuses, commissions, or other compensation, including distributions, taxable or non-
Yes
No
taxable, in addition to your regular salary?
If yes, explain:
5.
Does your employer pay for or provide you with an automobile (lease or purchase), automobile expenses,
Yes
No
gas, repairs, lodging and other.
If yes, explain.:
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
Page 4 of 10

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