Appendix V - Family Part Case Information Statement Form Page 6

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Part D - Monthly Expenses (computed at 4.3 wks/mo.)
Joint Marital or Civil Union Life Style should reflect standard of living established during marriage or civil union. Current
expenses should reflect the current life style. Do not repeat those income deductions listed in Part C – 3.
Joint Life Style
Current Life Style
Family, including
Yours and
children
children
SCHEDULE A: SHELTER
If Tenant:
Rent
...............................................................................................................
$
$
Heat (if not furnished)
...................................................................................
$
$
Electric & Gas (if not furnished)
..................................................................
$
$
Renter’s Insurance
........................................................................................
$
$
Parking (at Apartment)
..................................................................................
$
$
Other charges (Itemize)
.................................................................................
$
$
If Homeowner:
Mortgage ........................................................................................................
$
$
Real Estate Taxes (if not included w/mortgage payment)
...........................
$
$
Homeowners Ins. (if not included w/mortgage payment)
...........................
$
$
Other Mortgages or Home Equity Loans
......................................................
$
$
Heat (unless Electric or Gas)
.........................................................................
$
$
Electric & Gas
............................................................................................
$
$
Water & Sewer
............................................................................................
$
$
Garbage Removal
..........................................................................................
$
$
Snow Removal
..............................................
$
$
Lawn Care
.....................................................................................................
$
$
Maintenance/Repairs
............................................................................
$
$
Condo, Co-op or Association Fees
..........................................................
$
$
Other Charges (Itemize)
................................................................................
$
$
Tenant or Homeowner:
Telephone
......................................................................................................
$
$
Mobile/Cellular Telephone ............................................................................
$
$
Service Contracts on Equipment
.................................................................
$
$
Cable TV
......................................................................................................
$
$
Plumber/Electrician
.......................................................................................
$
$
Equipment & Furnishings
.............................................................................
$
$
Internet Charges .............................................................................................
$
$
Home Security System
..............................................
$
$
Other (itemize)
$
$
TOTAL
$
$
SCHEDULE B: TRANSPORTATION
................................................................................................
$
$
Auto Payment
..............................................
$
$
Auto Insurance (number of vehicles:
)
.....................................................................................
$
$
Registration, License
.................................................................................................
$
$
Maintenance
.................................................................................................
$
$
Fuel and Oil
...................................................................................
$
$
Commuting Expenses
...............................................................................
$
$
Other Charges (Itemize)
TOTAL
$
$
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
Page 6 of 10

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