Income And Expense Statement For Defendant Page 2

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EXPENSES
Do not list expenses which are paid by payroll deduction.
Housing, expenses per month:
Rent, mortgage, agreement of sale………………... $
Insurance if not included above …………………. $
Real Property taxes (if paid separately) …………. $
Utilities, gas, water, elec., telephone etc. ………… $
Transportation, expenses per month:
Car payment, lease, rental. ………………………. $
Insurance on vehicle. ……………………………. $
Maintenance (repairs) ………………………..…. $
Operating (gas, oil & tires) ……………..………. $
Total Housing and Transportation expenses…………………………………………………….……. $
Debt service (all monthly payments, eg. credit cards, charges, finance company, personal loans)
Personal Expenses per month:
Self
Children No. (
)
Food……………………………………………...
$
$
Clothing………………………………………….
$
$
Medical and Dental .…………………………….
$
$
Laundry and Cleaning. ………………………….
$
$
Personal articles ………………………………...
$
$
Recreation (movies, etc.) ……………………….
$
$
School (include food) ………………………….
$
$
Household. ………………………………..…….
$
$
Bus (on monthly basis) ……………………..….
$
$
Other (
). …………………….
$
$
Payment to others for dependent care ………….
$
$
Sub Totals …………………………….
$
Total Personal expenses ……………………………………..…….
$
Grand Total expenses: Housing, Trans., Debt & personal ……………………………….
$
Savings, <Deficiency>: Income minus Expenses. ……………………………………….
$
Explain in detail where savings are invested, or if there is a deficiency, who provides the funds to maintain the level
of spending indicated in this income and expense statement. (Use separate sheet if more space is needed.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CERTIFICATION
I hereby declare under the penalty of perjury that I have supplied the information used in this Income and Expense Statement
and have reviewed this statement and I certify that the information is accurate, complete and correct.
DATE
DEFENDANT’S SIGNATURE

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