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A. Gross monthly income from wages

B. Minus the following adjusments:

< Federal withholding tax

< State withholding tax

< FICA

< Union dues

<

Retirement contributions< Health/life insurance

< Medicare

< Other (describe)

Total adjustments to wages

D. Child support received

C. Maintenance received net of taxes

E. Other income received net of taxes (e.g., bonuses, rental income, investment income, etc.)

TOTAL AVERAGE NET MONTHLY INCOME

I. AVERAGE MONTHLY INCOME

Total general household expenses

< Home repair and maintenance

< Phone service - cell

< Phone service - land line

< Internet access

< Cable television

< Water and sewer

< Heating fuel (oil, gas, propane, wood, etc.)

< Electricity

B. General household expenses

A. Rent or home mortgage payment

II. AVERAGE MONTHLY EXPENSES

< Yard maintenance (mowing, snow removal, etc.)

<  Trash pickup

< Other (describe)

C. Motor vehicle expenses

Total motor vehicle expenses

< Inspection and licensing

< Maintenance and repair

< Gasoline/diesel

< Loan or lease payment

< Other (describe)

Prepared:

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Petitioner:

Respondent:

County:

Income & Expense Statement 

Case No:Petitioner

RespondentStatement of:

Instuctions: Monthly averages should be used for

all income and expense items even though

income and/or expense is not received/paid on a

montly basis. If item is received/paid on an

irregular basis, take annual amount and divide by

twelve.

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TOTAL AVERAGE MONTHLY EXPENSES

Total insurance expenses< Other (describe)

< Motor vehicle insurance

< Homeowner's/renter's insurance

< Disability insurance

< Health insurance for spouse/children

< Health insurance for yourself 

< Life insurance for souse/children

< Life insurance for yourself 

D. Insurance expenses (not included above)

F. Real estate and personal property taxes

< Credit card (list)

< Unsecured (list)

< Secured (list)

E. Loan and credit card expenses (not included above)

G. Court ordered child support/maintenance payments

H. Church and charitable contributions

I. Day care costs

Total other monthly living expenses

< Recreation and entertainment

< Professional dry cleaning and laundry

< Uninsured eye care

< Uninsured dental and orthodontic

< Uninsured medical care and medications

< Clothing

< Meal eaten away from home

< Groceries, household goods, supplies, etc.

 J. Other monthly living expenses Yourself Children

< Other (describe)

< Extracurricular fees (clubs, sports, lessons, etc.)

< School room and board

<

School tuition, books, supplies and fees

< Beauty and barber shop

III. RECAPITULATION

A. Net monthly income

B. Minus average monthly expenses

TOTAL MONTHLY NET DISPOSABLE INCOME

Total loan expenses

©Williams, Robinson, Rigler & Buschjost, P.C. - 2005 - Rev. 20050902 Page 2 of 2

IV. SIGNATURES

Signed By

Subscribed and sworn to before me on the _____ day of _________________________, 20_____.

Notary Public

I hereby declare under penalties of perjury that the foregoing information is true and correct to the best of my

knowledge and belief.