Statement Of Income And Expenses - Family Court Of St Louis County, Missouri
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4IN THE FAMILY COURT OF ST. LOUIS COUNTY, MISSOURI
For File Stamp Only
Petitioner
Date
vs.
__________________________
Case Number
__________________________
Respondent
Division
STATEMENT OF INCOME AND EXPENSES OF
NAME
SOCIAL SECURITY NUMBER
INCOME
1.
A. Name and address of employer
Gross Wages or Salary and Commission each Pay Period
$
PAID:
Weekly
Bi-weekly
Semi-monthly
Monthly
Number of Dependents Claimed
PAYROLL DEDUCTIONS:
FICA (Social Security Tax)
$
Medicare
$
Federal Withholding Tax
$
State Withholding Tax
$
City Earnings Tax
$
Union Dues
$
Others:
____________________________________________________
____________________________________________________
Total Deductions each Pay Period.
$
NET TAKE HOME PAY EACH PAY PERIOD
$
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