Uniform Income & Expense Statement Page 2
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4Do you support other children in your home or have a support order for children not in your home?
Yes No If yes, list them below.
Child’s First Name
Date of
Relationship
If there is an order for you to
Child 18 in
Birth
(daughter,
pay support, provide state,
High School
son, etc.)
county & court number.
in Your Home
Yes
No
List biological and adopted children or stepchildren you are ordered to support. List other children you support on a separate piece of paper.
Do you pay or receive spousal support? Yes No
Amount paid: $
to whom
Amount received: $
from whom
Are you employed? Yes
No
Name, address, & phone number of employer:
How many hours per week do you work?
Do you consistently receive wages for overtime
hours? Yes No
What is your monthly income before deductions? $
. Attach a copy of your most recent
pay stub.
Do you pay mandatory union dues? Yes No If yes, how much per month? $
Do you receive expense reimbursements or allowances for a car, cell phone, housing, subsidies, or any
other expenses which reduce your living expenses? Yes No If yes, how much per month? $
Attach proof you receive expense reimbursements or allowances.
Are you unemployed? Yes No
Are you receiving workers' compensation or unemployment benefits? Yes No
If yes, list the source and the amount of the monthly or weekly benefit:
Monthly Weekly
Source:
Amount: $
What type of work have you done in the last five years?
Why did your last job end?
Are you self-employed? Yes No
Name, address, & phone number of your business:
Attach a copy of your most recent tax return (personal and business, including all schedules) or
profit & loss statement.
Page 2 of 4 - UNIFORM INCOME & EXPENSE STATEMENT
CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:
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