Income And Expense Statement For Plaintiff
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1
2CASE NUMBER
STATE OF HAWAII
INCOME AND EXPENSE STATEMENT
FAMILY COURT
for PLAINTIFF
FC-D NO.
CIRCUIT
This document is prepared by
Plaintiff
Attorney For Plaintiff
Atty. For Defendant
_______________________________________
_______________________________________
PLAINTIFF
Name
(Your Full Name)
_______________________________________
_______________________________________
VS.
Address
_______________________________________
_______________________________________
City, State, Zip
_______________________________________
DEFENDANT
(Your Spouse’s Full Name)
Phone
______________________________________________________________________________
Occupation:
Job Title
______________________________________________________________________________
Employer:
______________________________________________________________________________
Address:
Length of Service:
months/years.
.
Income Tax Withholding based on:
dependants
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 …….. $
nd
Other regular monthly income, (rental income, 2
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) $
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