Income And Expense Declaration Page 3
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4FL-150
CASE NUMBER:
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/CLAIMANT:
The following people live with me:
12.
How the person is
That person's gross
Pays some of the
Name
Age
related to me? (ex: son)
monthly income
household expenses?
a.
Yes
No
Yes
No
b.
c.
Yes
No
Yes
No
d.
e.
Yes
No
Average monthly expenses
Proposed needs
13.
Estimated expenses
Actual expenses
Home:
a.
Laundry and cleaning . . . . . . . . . . . . . . . . . $
h.
i.
Clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
(1)
Rent or
mortgage. . . $
j.
Education . . . . . . . . . . . . . . . . . . . . . . . . . .
$
If mortgage:
k.
Entertainment, gifts, and vacation. . . . . . . . $
(a)
average principal:
$
average interest:
(b)
$
Auto expenses and transportation
l.
(insurance, gas, repairs, bus, etc.) . . . . . . .
$
Real property taxes . . . . . . . . . . . . . . $
(2)
Insurance (life, accident, etc.; do not
m.
(3)
Homeowner's or renter's insurance
include auto, home, or health insurance). . . $
$
(if not included above) . . . . . . . . . . . .
n.
Savings and investments. . . . . . . . . . . . . . . $
(4)
Maintenance and repair . . . . . . . . . . .
$
o.
Charitable contributions. . . . . . . . . . . . . . . . $
Health-care costs not paid by insurance. . .
b.
$
p.
Monthly payments listed in item 14
Child care . . . . . . . .. . . . . . . . . . . . . . . . . . $
c.
(itemize below in 14 and insert total here). .
$
q.
Other (specify): . . . . . . . . . . . . . . . . . . . . . . $
d.
Groceries and household supplies. . . . . . .
$
Eating out. . . . . . . . . . . . . . . . . . . . . . . . . .
e.
$
TOTAL EXPENSES (a–q) (do not add in
r.
f.
Utilities (gas, electric, water, trash) . . . . . .
the amounts in a(1)(a) and (b))
$
$
Telephone, cell phone, and e-mail . . . . . . .
g.
$
s.
Amount of expenses paid by others
$
14.
Installment payments and debts not listed above
Date of last payment
Paid to
For
Amount
Balance
$
$
$
$
$
$
$
$
$
$
$
$
15.
Attorney fees (This is required if either party is requesting attorney fees.):
a.
To date, I have paid my attorney this amount for fees and costs (specify): $
b.
The source of this money was (specify):
c.
I still owe the following fees and costs to my attorney (specify total owed): $
d.
My attorney's hourly rate is (specify): $
I confirm this fee arrangement.
Date:
(TYPE OR PRINT NAME OF ATTORNEY)
(SIGNATURE OF ATTORNEY)
FL-150 [Rev. January 1, 2007]
INCOME AND EXPENSE DECLARATION
Page 3 of 4
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