Financial Statement Page 5
ADVERTISEMENT
1
2
3
4
5
6
7PART III. INCOME AND EXPENSES
This part must be completed in any case which involves alimony and/or attorney fees. If you need additional space, attach separate
sheets.
A. INCOME AND MONEY RECEIVED. Include all gross income and other money from all sources, whether taxable or not.
Give current actual amount if known. If you do not know or cannot obtain actual amounts, give your best estimate.
Use applicable period, either:
Weekly
Monthly
Yearly
1. Wages/Self-employment (Show deductions in B1 below)
$
$
$
2. Bonuses
$
$
$
3. Commissions/Tips
$
$
$
4. Unemployment Payments
$
$
$
5. Workers’ Compensation/Disability Payments
$
$
$
6. Public Assistance
$
$
$
7. Pensions/Annuities
$
$
$
8. Interest/Dividends/Investment income
$
$
$
9. Partnerships/Trusts/Royalties
$
$
$
10. Rental income
$
$
$
11. Military Reserve/National Guard income
$
$
$
12. Employer furnished benefits (e.g., car, room, insurance)
$
$
$
13. Other (specify)
$
$
$
TOTAL INCOME
$
$
$
B. EXPENSES AND DEDUCTIONS. List all expenses paid and amounts deducted from gross income from wages and self-
employment. If any payment you list is a payment on a debt, show the section and item number where that debt is listed in Part II,
Section I, Debts, on page 4.
1.
DEDUCTIONS FROM WAGES AND SELF-EMPLOYMENT INCOME.
Use applicable period, either:
Weekly
Monthly
Yearly
Section and Item No. -|
a) Federal income tax (Number of exemptions_____)
$
$
$
b) State income tax
$
$
$
c) F.I.C.A.
$
$
$
d) Self-employment tax
$
$
$
e) Medical insurance
$
$
$
f) Union dues
$
$
$
g) Payment on loans
$
$
$
h) Savings/Bonds
$
$
$
i) Retirement
$
$
$
j) Support payments/Alimony
$
$
$
k) Other (Specify)
$
$
$
TOTALS
$
$
$
Pursuant to M.R.Civ.P. 108(d)(3), the information on this form is not subject to public inspection.
Page 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial