Financial Statement Template Page 2
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2Total Monthly Income: Include income from all sources including self-employment, rent, royalties,
business income, salaries, wages, commissions, bonuses, dividends, pensions, interest, trusts, annuities,
social security benefits, workers compensation, unemployment benefits, disability benefits, alimony or
maintains received, tips, income from side jobs, severance pay, capital gains, gifts, prizes, lottery
winnings, etc. Do not report benefits from means-tested public assistance programs such as food stamps
or AFDC.
Extraordinary Medical Expenses: Uninsured expenses over $100 for single illness or condition
including orthodontia, dental treatment, asthma treatment, physical therapy, treatment for any chronic
health problems, and professional counseling or psychiatric therapy for diagnosed mental disorders.
Child Care Expenses: Actual child care expenses incurred on behalf of a child due to employment or
job search of either parent with amount to be determined by actual experience or the level required to
provide quality care from a licensed source.
School and Transportation Expenses: Any expenses for attending a special or private elementary or
secondary school to meet the particular needs of the child or expenses for transportation of the child
between the homes of the parents.
DR 30 (Revised 11/2000)
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