Source of Income
Amount per Month
Child Support
Dependent’s Benefits
Other Income (describe):
4.
Disclosure of Expenses
The [ ] Petitioner/[ ] Respondent has the following expenses:
Description of Expense
Amount per Month
Taxes and other money withheld from income
Retirement
Health Insurance (self and children)
Medical Expenses
Housing (rent or mortgage payment)
Property Taxes
Property Insurance
Transportation
Car Insurance
Student Loans
Utilities
Telephone
Clothing
Food and Household Supplies
Child Care
Child Support Payments
Declaration of Disclosure, Page 7 of 8
Approved by the Montana Supreme Court Commission on Self-Represented Litigants and Montana Legal Services Association, 7/24/02