Form 16(a)SS (Rev. 01/11) The Family Court of the State of Delaware In and For New Castle Kent Sussex County FINANCIAL REPORT FOR SPOUSAL SUPPORT Name Address P.O. Box Number City/State/Zip Code Home Phone Number Attorney Name D.O.B. Employers Name Address P.O. Box Number City/State/Zip Code Employer Phone Number Date of Hire File Number Petition Number EIN (Federal Identification) Number of Employer I. EMPLOYMENT AND INCOME A. If unemployed or employed less than full time or if income is limited for medical or other reasons, please briefly describe the reason(s) and attach any supporting documentation. B. List average monthly payroll income and income deduction during preceding twelve (12) months. If paid weekly, multiply by 52 and divide by 12; if paid on alternate weeks, multiply by 26 and divide by 12; if paid twice per month multiply by 2. Please attach supporting documentation such as pay stubs and tax returns. Income Type Wage/salary - including overtime $ Tips, commissions and bonuses $ Wage/salary - second job $ Employer provided housing/transp. $ Geographic cost of living stipend $ Gross Proceeds from self-employment $ Net Income from self-employment $ Interest, dividends, investments $ Social Security (SSD or SSR) $ Supplemental Security Income (SSI) $ Unemployment or Worker's Compensation $ Other pension, retirement or disability $ TOTAL NET INCOME $ Amount per per per per per per per per per per per per Required Documentation Pay stubs, tax return, W-2 form Pay stubs, tax return, W-2 form Pay stubs, tax return, W-2 form 1099 Pay stubs, letter from employer IRS Schedule C, 1099 forms Tax return, IRS Schedule C Tax return, 1099 forms Social Security statement Social Security statement Check stub, insurer statement Tax return, 1099, payor letter Bring copies of your last three pay stubs and most recent tax return with all schedules and W-2 statements to every mediation conference and hearing. If self employed, the Schedule C from your last tax return with all 1099 forms is also required. Other documents may be needed depending on the facts of your case . Attachment checklist: Pay stubs Tax Return(s) W-2 Form(s) 1099 Form(s) Health Insurance Schedule C Childcare Other Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 16(a)SS (Rev. 01/11) II. Deduction Type Medical Insurance $ Life Insurance $ Union Dues $ Pension Contribution $ Other mandatory deductions (list item and amount) $ TOTAL DEDUCTIONS $ DEDUCTIONS per per per per Required Documentation Pay stubs, brochure Pay Stubs Pay stubs Pay stubs Pay stubs Amount III. EXPENSE INFORMATION Monthly expenses (1/12 of actual payments made during preceding twelve (12) months and present or projected costs based on recent experience). Expense Type Rent Mortgage (tax, insurance, escrow) Car Payment/Transportation Expense Water Sewer Electric Gas and/or Oil Garbage Cable TV Telephone Cell Phone Groceries (including household & Personal items) Amount per per per per per per per per per per per per per per per per per per Required Documentation Clothing Out-of-pocket medical expenses Medical expenses for Chid(ren) Child Support Child Care Costs Other mandatory deductions (list item and amount) TOTAL EXPENSES Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Form 16(a)SS (Rev. 01/11) IV. CURRENT PROVISIONS AVAILABLE/USED Please list the provisions currently being provided and/or available and if they are being used. Currently Used Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No Description House/Apartment/Townhouse Vehicle: Year: Make: Model: Bank Account: Savings Checking Bank Account: Savings Checking Rent Mortgage (tax, insurance, escrow) Car Payment/Transportation Expense Water Sewer Electric Gas and/or Oil Garbage Cable TV Telephone Cell Phone Groceries (including household & Personal items) Amount per per per per per per per per per per per per per per per per per per per per per per per Required Documentation Clothing Out-of-pocket medical expenses Medical expenses for Chid(ren) Child Support Child Care Costs Other mandatory deductions (list item and amount) TOTAL Date Signature Attorney Sworn to subscribed before me this ______ day of ______________________, _________ Mediator/Notary Public Date Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com