Income And Expense Declaration Page 2

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FL-150

PETITIONER/PLAINTIFF:

CASE NUMBER:

RESPONDENT/DEFENDANT:

OTHER PARENT/CLAIMANT:

Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal

tax return to the court hearing. (Black out your social security number on the pay stub and tax return.)

Income (For average monthly, add up all the income you received in each category in the last 12 months

Average

and divide the total by 12.)

monthly

Last month

Salary or wages (gross, before taxes). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Overtime (gross, before taxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Commissions or bonuses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Public assistance (for example: TANF, SSI, GA/GR)

currently receiving . . . . . . . . . . . . . . . . .

Spousal support

from this marriage

from a different marriage . . . . . . . . . . . . . . . . . .

Partner support

from this domestic partnership

from a different domestic partnership

Pension/retirement fund payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Social security retirement (not SSI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Disability:

Social security (not SSI)

State disability (SDI)

Private insurance .

Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Workers' compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Other (military BAQ, royalty payments, etc.) (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Investment income (Attach a schedule showing gross receipts less cash expenses for each piece of property.)

Dividends/interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rental property income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Trust income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Other (specify): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Income from self-employment, after business expenses for all businesses. . . . . . . . . . . . . . . . . . . . . $

I am the

owner/sole proprietor

business partner

other (specify):

Number of years in this business (specify):

Name of business (specify):

Type of business (specify):

Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your

social security number. If you have more than one business, provide the information above for each of your businesses.

Additional income.

I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months (specify source and

amount):

Change in income.

My financial situation has changed significantly over the last 12 months because (specify):

10.

Deductions

Last month

Required union dues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

b. Required retirement payments (not social security, FICA, 401(k), or IRA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Medical, hospital, dental, and other health insurance premiums (total monthly amount). . . . . . . . . . . . . . . . . . . . . . . .

d. Child support that I pay for children from other relationships. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

e. Spousal support that I pay by court order from a different marriage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

f. Partner support that I pay by court order from a different domestic partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Necessary job-related expenses not reimbursed by my employer (attach explanation labeled "Question 10g") . . . . .

11.

Assets

Total

Cash and checking accounts, savings, credit union, money market, and other deposit accounts . . . . . . . . . . . . . . . .

Stocks, bonds, and other assets I could easily sell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

All other property,

real and

personal

(estimate fair market value minus the debts you owe) . . . .

FL-150 [Rev. January 1, 2007]

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INCOME AND EXPENSE DECLARATION