State of Alabama Unified Judicial System Form C-58 NOTICE OF REFERENCE AND QUESTIONNAIRE Rev.2/79 Case Number IN THE________________________________________COURT OF _____________________________________, ALABAMA (Circuit or District) (Name of County) _________________________________________________v. ____________________________________________________ Plaintiff Defendant Pursuant to an Order of Reference in the above-entitled case in the court, I have appointed and designated (date) _____________________ (time).____________. M. at my office (location) ___________________________________________ for considering the matters thereby referred to me, at which time and place all parties are to attend. Date_________________________ Clerk _____________________________________________________________ 1. 2. 3. 4. Date of (Marriage) __________________________(Separation)__________________________________________________ Ages of Dependent Child of this marriage: ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) What is the condition of your health? _______________________________________________________________________ List any specific health needs or requirements for the minor children of this marriage. _________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. What are your necessary monthly living expenses? (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) (o) (p) Rent House Payment Utilities: Lights Water Gas Telephone Food Doctor Dentist Drugs Life Insurance Hospitalization Liability Insurance Collision Insurance Fire Insurance Car Payment Gasoline and Oil Car Repairs Other Transportation $ ___________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ _____________________ $ __________________ (q) (r) (s) (t) (u) (v) (w) (x) (y) Furniture Church Gifts Newspaper Lunches, School Beauty Parlor Haircuts Entertainment Child care (z) List all fixed credit obligations or debts owed: Owe to whom ___________________ ___________________ ___________________ ___________________ ___________________ $ _________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $ ____________________ $_____________________ Balance Owed Monthly Payment _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ TOTAL________________ 6. Are you working: __________________ Kind of work: _____________________________ Badge No. _____________ Employer: ______________________________ Social Security No. ________________ Hourly rate of Pay. ________ 7. GROSS INCOME DEDUCTIONS: Withholding Tax FICA Retirement Credit Union Union Dues _________________ _________________ TOTAL $ ________________ Weekly Monthly $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ NET INCOME ( Take Home Pay) $ _____________ Weekly Monthly 8. Other Income Explain: _________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ (PLEASE FILL IN AND COMPLETE BACK OF PAGE) American LegalNet, Inc. www.USCourtForms.com C-58 (back) 9. Is your spouse working? _______________________ Kind of Work _____________________________________________ 10. GROSS INCOME DEDUCTIONS: Withholding Tax FICA Retirement Credit Union Union Dues _________________ _________________ TOTAL $ ________________ Weekly Monthly $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ $ ___________________ NET INCOME (Take Home Pay) Weekly $ ________________ Monthly 11. Other Income (Spouse): Explain: _________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 12. Physical custody and residence of Children is at present, as follows: _____________________________________________ ____________________________________________________________________________________________________ 13. The following sums are reasonably necessary, or within the ability of my husband to pay, and it will be fair and equitable to require the following based on his earnings and our debts: TOTAL Week $ ________________ $ ________________ $ ________________ TOTAL a. b. $ _______________ $ _______________ $ _______________ $ _______________ For Temporary Alimony For Child Support 14. Wife’s Net Income 15. Husband’s Net Income Less Alimony and Support Net to Husband after Deduction of Child Support and Alimony Month $ ________________ $ ________________ $ ________________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ $ _______________ 16. (Answer only if Husband). I feet that a reasonable sum for me to pay based on my earnings and our debts: a. b. For Temporary Alimony For Child Support TOTAL Week $ ________________ $ ________________ $ ________________ Month $ ________________ $ ________________ $ ________________ I swear that these answers are true and reflect my present financial status. I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury. ____________________________ Date ___________________________________________________ Affiant Sworn Before Me This Date ____________________________ ___________________________________________________ Clerk American LegalNet, Inc. www.USCourtForms.com