Short Form Financial Declaration Page 5
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85.
I have a vehicle and pay the following each month:
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Vehicle payment each month in the amount of:
$ _________________
Fuel for the vehicle in the amount of:
$ ________________
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Insurance for the vehicle (if paid over a period of
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six months or a year, average the payment out)
$ ________________
Repairs and maintenance (averaged over a year)
$ ________________
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6.
I do not own a vehicle but my monthly transportation costs
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(bus, taxi, etc.) are:
$ _________________
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7.
I have medical bills that I pay on each month in the amount of:
$ ________________
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8.
I have medical prescriptions each month in the amount of:
$ _________________
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9.
I pay health insurance (not deducted from my check) in the
amount of:
$ _________________
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10.
I am paying child support each month that is not deducted
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directly from my paycheck in the amount of
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(amount of court order $_____________):
$ _________________
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11.
I am also legally responsible for the support of others, namely:
_________________________________________________
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each month in the amount of
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(amount of court order $_____________):
$_________________
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12.
Each month I pay child care in the amount of:
$ _________________
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13.
I have credit card /charge account payments each month and pay
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those charges as follows:
Name of Credit Card or Charge Account
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________________________________________in the amount of: $ ________________
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________________________________________in the amount of: $ _________________
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________________________________________in the amount of $ _________________
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________________________________________in the amount of $ __________________
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________________________________________in the amount of $ __________________
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________________________________________in the amount of $ __________________
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14.
Clothing, cleaning, laundry, etc. each month:
$ _________________
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15.
I have school or educational expenses each month of:
$ _________________
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