Income And Expense Statement Template

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CASE NUMBER
STATE OF HAWAI‘I
INCOME AND EXPENSE STATEMENT
FAMILY COURT
Plaintiff
Defendant
FC-D NO.
THIRD CIRCUIT
This document is prepared by
Plaintiff
Defendant
Atty. for Plaintiff
Atty. for Defendant
PLAINTIFF
_________________________________________________
(Full Name)
Name
_________________________________________________
VS.
_________________________________________________
Address
_________________________________________________
City, State, Zip
DEFENDANT
_________________________________________________
(Full Name)
Phone
Occupation:
_________________________________________________________________________________
Job title
Employer:
__________________________________________________________________________________
Address:
___________________________________________________________________________________
Length of service:
_____________
months/years.
Income Tax Withholding based on:
________ dependents.
INCOME
Gross income. Paid:
monthly,
2 times per month,
every 2 weeks,
weekly
or other
___________
Gross per pay period
...................................... $ ___________
Per month
............................... $ ____________
Payroll deductions per pay period:
Fed. income tax
.......................................
$ ____________
State income tax
......................................
$ ____________
FICA (Social Security)
............................
$ ____________
Union dues
..............................................
$ ____________
a) Net per pay period
................... $ ___________
Per month
........ $ _____________
Other:
Retirement/401K
...................................
$ ____________
Credit Union
..........................................
$ ____________
Direct Deposit
.......................................
$ ____________
Income Assignments
..............................
$ ____________
Support Payments
..................................
$ ____________
Medical Insurance
.................................
$ ____________
b) Take home per pay period
....... $ ___________
Per month
........ $ _____________
Other regular monthly income, (rental income, 2nd job, interest, child support, welfare, food
stamps, and any other source.)
Gross monthly receipt
.............................
$ ____________
Taxes paid IRS and State on above
..........
$ ____________
c) Total other income net
...............................
$ ____________
Total Monthly Income (Add per month income from lines a and c above)
$ _____________
RevaComm 508 Certified
FORM NO. 073917
INCOME & EXPENSE STATEMENT 3F-P-270
REPROGRAPHICS (6/08)
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