Personal Data Form And Social Study Information Sheet - Tarrant County Family Court Services Page 6
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16REASON FOR LEAVING: ____________________________________________________________________________________
YOUR SALARY OR HOURLY WAGE: _____________________________
4. EMPLOYER: ____________________________________________________________________________________________
ADDRESS: _________________________________________________________________________________________________
YOUR TITLE/POSITION: ______________________DATE EMPLOYED: ______________DATE LEFT: ___________________
SUPERVISOR: _____________________________ PHONE NO.: ____________________________FAX NO. ________________
REASON FOR LEAVING: ____________________________________________________________________________________
FINANCIAL STATEMENT
MONTHLY NET INCOME (LIST ALL SOURCES):
SOURCE
AMOUNT
_____________________________________________________________________________
_______________
______________________________________________________________________________ _______________
______________________________________________________________________________ _______________
______________________________________________________________________________ _______________
TOTAL
==============
If you pay child support, is it taken out of your pay check? YES NO
MONTHLY EXPENSES
Housing:
1.
Rent/House Payment
$______________
2.
Insurance (Home/Tenant)
$______________
3.
Maintenance, repair and service
$______________
4.
Utilities (Gas, water, electric)
$______________
5.
Telephone
$______________
Auto:
1.
Car Payments
$______________
2.
Insurance
$______________
3.
Gasoline & Oil
$______________
4.
Maintenance & Repair
$______________
Insurance:
1.
Life
$______________
2.
Health and Hospitalization
$______________
3.
Other
$______________
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