Financial Information Statement Form

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NOTICE:
This form is to be completed and a copy furnished to opposing counsel and to the Clerk of the
Court prior to the hearing. All columns must be totaled. Provide past 2 years IRS returns and 2
most recent payroll stubs and if none, provide W-2 forms.
FINANCIAL INFORMATION STATEMENT
NO. _________________________________________
_____________ District Court
____________________________________________
_____________________________________________
PETITIONER
RESPONDENT
____________________________________________
_____________________________________________
ATTORNEY
ATTORNEY
1.
Date of Marriage: _________________________
Date of Separation: _____________________________
2.
Ages of Children:
(
)
(
) (
)
(
) (
)
(
)
(
)
(
)
(
)
3.
GROSS MONTHLY RESOURCES:
WIFE
HUSBAND
Wages/Salary
$ ________________________
_________________________
Overtime
_________________________
_________________________
Bonus
_________________________
_________________________
Commissions/Tips
_________________________
_________________________
Interest on Savings
_________________________
_________________________
Dividends
_________________________
_________________________
Royalty Income
_________________________
_________________________
Trust Income
_________________________
_________________________
Net Rental Income
_________________________
_________________________
Retirement/Pension Income
_________________________
_________________________
Annuities
_________________________
_________________________
Capital Gains
_________________________
_________________________
Social Security Benefits
_________________________
_________________________
Unemployment Benefits
_________________________
_________________________
Disability/Workman's Comp.
_________________________
_________________________
Interest on Notes
_________________________
_________________________
Accounts Receivable
_________________________
_________________________
Spousal Support/Alimony
_________________________
_________________________
Other Income
_________________________
_________________________
TOTAL RESOURCES:
$ ________________________
$ ________________________
4.
DEDUCTIONS:
Withholding Tax
($ _______________________ )
($ ________________________)
FICA
( ________________________ )
( _________________________)
Retirement
( ________________________ )
( _________________________)
Union Dues
( ________________________ )
( _________________________)
Health Insurance
( ________________________ )
( _________________________)
Health Insurance for Children
( ________________________ )
( _________________________)
Miscellaneous
( ________________________ )
( _________________________)
TOTAL DEDUCTIONS:
($ _______________________ )
($ ________________________)
5.
NET MONTHLY INCOME:
$
$
6.
EMPLOYMENT:
WIFE _______________________________________________________________________________________
HUSBAND ___________________________________________________________________________________
¨ week
¨ two weeks
¨ bimonthly
¨ month
WIFE IS PAID EVERY:
¨ week
¨ two weeks
¨ bimonthly
¨ month
HUSBAND IS PAID EVERY:
Date Next Check is Received: WIFE____________________ HUSBAND_____________________
7.
QUICK ASSETS:
WIFE
HUSBAND
Cash/Undeposited Checks
$ ________________________
$ ________________________
Financial Institutions
_________________________
_________________________
Stocks/Bonds
_________________________
_________________________
Other
_________________________
_________________________
I can borrow $________________________________ on my signature.
S:\FormsLib\Civil Bureau\Fam Juv & IVD Courts\Famcrt\Financial Information Form for Family Courts
Revised 5/29/96

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