IN THE vs. C OURT OF DAVIDSON COUNTY, TENNESSEE Complainant CASE NO. Defendant INCOME AND EXPENSE STATEMENT INCOME : It is mandatory to attach payroll records, leave earning statements from the military, or other proof of income for the past six most recent pay periods. A. 1. Employer: Address: 2. My gross wages and commission: Weekly Twice Monthly Monthly $ 3. Deductions each pay period: Federal Tax FICA Other $ 4. Net take-home earnings on a basis $ Other income (from any source): B. ................................................................... $ NET TAKE-HOME MONTHLY TOTAL Other Household Residents: C. 1. Name: Relationship to party: Net Income 2. Name: Relationship to party: Net Income D. Health Insurance: 1. Provided by employer : Cost to me: (yes/no) 2. Self-employed or provide own insurance: Cost to me: (yes/no) 3. No Health Insurance: 4. Coverage for Self Spouse # of Children Others EXPENSES: Monthly Household Expenses: A. Rent/mortgage (including taxes and insurance) Water Electric Phone Car Operation Insurance Auto Payment Household Loans Other Monthly Payments B. General: Food Clothing Medical & Dental Laundry & Cleaning Recreation (specify) School Expenses Child Care Beauty/Barber Shop Other (specify) Other (specify) Other (specify) SUB-TOTALS Myself Gas $ $ Total Utilities $ Children (# ) Total $ $ TOTAL ALL EXPENSES $ ......................................... $ ............................... $ Total General C. Anticipated Future Expenses (Attached) I need $ (Weekly/Monthly) NET INCOME LESS EXPENSES Last four digits of Social Security Number Sworn to and subscribed before me this day of Plaintiff/Defendant , 20 . My Commission Expires: Signature of Notary Public Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com