Mandatory Case Disclosure Page 3
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13(I) Does Petitioner have any other sources of income?
Source(s):
Average Amount:
per " week, " month, " year.
2)
(J) INFORMATION ON RESPONDENT:
Name:
Address:
Telephone Number:
Age:
Date of Birth:
Check One:
" EMPLOYED " UNEMPLOYED " DISABLED " RETIRED
(K) If Respondent is Employed:
Employer’s Name:
Employer’s Address:
Employer’s Telephone Number:
Respondent started working for this employer on
(date)
Check One:
" Respondent is paid by the hour. Respondent earns $_________ per hour and works
________ hours per week.
" Respondent is paid a salary. Respondent receives $___________________________
(amount of pay check before taxes)
" every week, " every two weeks, " twice a month, " once a month.
(L) If Respondent is Unemployed:
Name of Last Employer:
Address of Last Employer:
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