Financial Statement Page 7
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75.
HEALTH AND MEDICAL EXPENSES. List all health and medical expenses. 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.
Use applicable period, either:
Weekly
Monthly
Yearly
Section and Item No. -|
a) Doctors
$
$
$
b) Hospital expenses
$
$
$
c) Dentists/Orthodontist
$
$
$
d) Therapist
$
$
$
e) Medical/Dental insurance
$
$
$
f) Prescriptions
$
$
$
g) Other (Specify)
$
$
$
TOTALS
$
$
$
6.
CREDIT CARD, CHARGE ACCOUNT, AND LOAN PAYMENTS. List all credit card, charge account, and loan payments.
Show the section and item number where that debt is listed in Part II, Section I, Debts, on page 4
Use applicable period, either:
Weekly
Monthly
Yearly
Section and Item No. -|
a)
$
$
$
b)
$
$
$
c)
$
$
$
d)
$
$
$
e)
$
$
$
f)
$
$
$
g)
$
$
$
TOTALS
$
$
$
7.
MISCELLANEOUS EXPENSES. List all miscellaneous expenses. 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.
Use applicable period, either:
Weekly
Monthly
Yearly
Section and Item No. -|
a) Life insurance premiums
$
$
$
b) Entertainment/Recreation
$
$
$
c) Vacation expenses
$
$
$
d) Child care expenses
$
$
$
e) Support/Alimony payments
$
$
$
f) Newspapers/Periodicals
$
$
$
g) Other (Specify)
$
$
$
TOTALS
$
$
$
8.
OTHER EXPENSES NOT LISTED ELSEWHERE ON THIS FORM. If you have other expenses, e.g., allowances for
children, gifts, charities, etc., check here ❐ and list them on an attachment.
Important Notice
This Financial Statement must be updated and the updated statement filed with the court 7 days before trial.
M.R.Civ.P. 108(d)(4).
Pursuant to M.R.Civ.P. 108(d)(3), the information on this form is not subject to public inspection.
Page 7
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