Appendix V - Family Part Case Information Statement Form Page 7
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10SCHEDULE C: PERSONAL
Joint Life Style
Current Life Style
Family, including
Yours and
children
children
Food at Home & household supplies ...............................................................
$
$
Prescription Drugs ..............................................................................................
$
$
Non-prescription drugs, cosmetics, toiletries & sundries
...............................
$
$
School Lunch ....................................................................................................
$
$
Restaurants ........................................................................................................
$
$
Clothing .............................................................................................................
$
$
Dry Cleaning, Commercial Laundry
...............................................................
$
$
Hair Care ...........................................................................................................
$
$
Domestic Help ..................................................................................................
$
$
Medical (exclusive of psychiatric)* .................................................................
$
$
Eye Care* ..........................................................................................................
$
$
Psychiatric/psychological/counseling* ............................................................
$
$
Dental (exclusive of Orthodontic* ...................................................................
$
$
Orthodontic* .....................................................................................................
$
$
Medical Insurance (hospital, etc.)* ..................................................................
$
$
Club Dues and Memberships ...........................................................................
$
$
Sports and Hobbies ...........................................................................................
$
$
Camps ...............................................................................................................
$
$
Vacations ..........................................................................................................
$
$
Children’s Private School Costs .......................................................................
$
$
Parent’s Educational Costs ...............................................................................
$
$
Children’s Lessons (dancing, music, sports, etc.)
...........................................
$
$
Babysitting ........................................................................................................
$
$
Day-Care Expenses ..........................................................................................
$
$
Entertainment ....................................................................................................
$
$
Alcohol and Tobacco .......................................................................................
$
$
Newspapers and Periodicals .............................................................................
$
$
Gifts ..................................................................................................................
$
$
Contributions ....................................................................................................
$
$
Payments to Non-Child Dependents ................................................................
$
$
Prior Existing Support Obligations this family/other families
(specify)
......................
$
$
Tax Reserve (not listed elsewhere)
.................................................................
$
$
Life Insurance
.........................................................................................
$
$
Savings/Investment
................................................................................
$
$
Debt Service (from page 7) (not listed elsewhere)
.................................
$
$
Parenting Time Expenses
.......................................................................
$
$
Professional Expenses (other than this proceeding)
................................
$
$
Pet Care and Expenses
...............................................................................
$
$
Other (specify)
................................
$
$
*unreimbursed only
TOTAL
$
$
Please Note: If you are paying expenses for a spouse or civil union partner and/or children not reflected in this budget, attach a schedule of
such payments.
.................................................................................................
$
$
Schedule A: Shelter
....................................................................................
$
$
Schedule B: Transportation
...............................................................................................
$
$
Schedule C: Personal
............................................................................................................
$
$
Grand Totals
Revised to be effective September 1, 2017. CN: 10482 (Court Rules Appendix V)
Page 7 of 10
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