Financial Statement Template
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1
2Circuit Court for
City or County
Name
Name
Street Address
Apt. #
Street Address
Apt. #
Area
Area
Telephone
Telephone
City
State
Zip Code
City
State
Zip Code
Code
Code
Plaintiff
Defendant
FINANCIAL STATEMENT
(Short)
(DOM REL 30)
I,
, state that:
My name
I am the
mother/
father or
Check One
State Relationship (for example, aunt, grandfather, guardian, etc.)
of the minor child(ren):
Name of Child
Date of Birth
Name of Child
Date of Birth
Name of Child
Date of Birth
Name of Child
Date of Birth
Name of Child
Date of Birth
Name of Child
Date of Birth
The following is a list of my income and expenses (see below*):
See definitions on back before filling out.
Total monthly income (before taxes)
Child support I am paying for my other child(ren) each month
Alimony I am paying each month to
Name of Person(s)
Alimony I am receiving each month from
Name of Person(s)
For the child or children listed above:
Monthly health insurance premium
Work-related monthly child care expenses
Extraordinary monthly medical expenses
School and transportation expenses
*To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3 and yearly expenses should be divided
by 12. If you do not pay the same amount each month for any of the categories listed, figure what your average monthly expense
is.
I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the
best of my knowledge, information and belief.
Date
Signature
DR 30 (Revised 11/2000)
Reset
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Parent category: Financial