Uniform Income & Expense Statement Page 3
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4Do you have other income? Yes No Income includes but is not limited to, commissions,
advances, bonuses, dividends, severance pay, pensions, interest, Social Security benefits, disability
insurance benefits, prizes, lottery, alimony, Supplemental Security income, and distributions from a trust.
Income does not include child support, food stamp benefits, Social Security resulting from a child’s
disability, adoption assistance, guardianship assistance, and foster care subsidies.
Source:
Amount: $
Source:
Amount: $
Do you have child care costs for the ‘Joint’ children? Yes No
Are the children 12 years old or under? Yes No
Are the children disabled? Yes No
If you answered yes to either question, list the name(s) of the children, date(s) of birth and amount(s)
you pay for their care and attach proof of child care costs: (Only include the costs you pay out of
pocket.)
Amount: $
Amount: $
Amount: $
Amount: $
Are you paying for your own health care coverage? Yes
No If yes, what is your monthly cost?
$
. Attach proof of coverage showing your monthly cost.
Is health care coverage available for your children? Yes No If yes, who insures the children?
Source of insurance: employer other group spouse domestic partner other
Insurance Co.:
Phone #:
Address
Policy #:
Group #:
Effective date of the policy:
Monthly cost per child $
Name(s) of children currently covered by insurance:
Do you pay ongoing medical expenses for the children? Yes No
If yes, list the name(s) of children, the reason for the expense, and the monthly cost:
Amount: $
Amount: $
Attach proof of insurance and ongoing medical expenses for the children.
Do any of your children receive Social Security or Veteran’s benefits due to a parent=s disability or
retirement? Yes No
What type of benefit do they receive?
Survivors and Dependents Educational Assistance
Social Security benefits
Apportioned Veteran’s benefits due to the disability or retirement of a parent
What is the total monthly benefit amount the children receive? $
If your child is in state care, do you have regular visits? Yes No
If so, how far do you travel?
How often do you visit?
Does the Department of Human Services pay any of these expenses? Yes No
Page 3 of 4 - UNIFORM INCOME & EXPENSE STATEMENT
CSF 01 0100 (Rev. 04/18/14) CSCM Initials CSP#:
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