COURT SUPERIOR COURT OF THE DISTRICT OF COLUMBIA COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .COURT. . . . . . FAMILY . . . . . . ......... .. Jacket No. : Index No. FINANCIAL STATEMENT : V. SOCIAL SECURITY NO: NAME: Calendar No. OCCUPATION: : Plaintiff(s) -againstNAME AND ADDRESS OF CURRENT EMPLOYER: JUDICIAL SUBPOENA : : INCOME INFORMATION* : $ I claim exemptions for withholding tax purposes. AVERAGE MONTHLY EXPENSES Wife/Husband Housing, etc Rent/Mortgages $ Defendant(s) : 2. Less Mandatory Monthly Deductions: Utilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Taxes. . . . . . ... Federal Income Tax Food $ State Income Tax Groceries/Household Supplies Retirement: Meals Out FICA Automobile THE PEOPLE OF THE STATE OF NEW YORK Social Security Payment Medical Insurance Gas/Oil TO Other Repairs $ TOTAL Insurance $ Tags $ 3. Monthly Net Wages (Subtract Line 2 form line 1) Life Insurance GREETINGS: (List beneficiaries) 4. Monthly income form all other sources (e.g., part.time or overtime wages, fees WE COMMAND YOU, that all business and excuses being laid aside, you rents, dividends, commissions, unem. the Honorable at the Court ployment compensation, disability, located at County of interest, social security, retirement, Health Insurance (not listed as bonuses, etc.) room in , on the day $ of , 20 income deduction) o'clock in the , at 1. Monthly gross wages 5. Retirement: FICA , Your failure to comply with this subpoena isChild Care Expenses contempt of court and will make you liable to punishable as a the party on whose behalf this subpoena was issued forTo allow for employment/ of $50 and all damages sustained as a a maximum penalty Education result of your failure to comply. Witness, Honorable Court in County, Medical Insurance Other TOTAL To allow for recreation Lesson (e.g. music, dance, art) day of , 20 ClothingfUniforms Dry Cleaning/Laundry $ Monthly Net Income form All other sources , one of the Justices of the Allowance $ Medical Expenses (Attorney (Unpaid by Insurance) must sign above and type name below) (Subtract Line 5 from Line 4) Charitable Contributions Total Monthly Net Recreation Attorney(s) for Disposable Income $ Vacations Total Monthly Gross Income $ Miscellaneous: Total Monthly Gross Income $ (Add Lines I and 4) Office and P.O. Address SUMMARY 9. and each of you attend before Supplies/Fees Social Security 8. $ Tuition $ State Income Tax 7. Children noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Less Other Mandatory Monthly Deductions: School Federal Income Tax 6. Date Total Monthly Net Disposable Income Period Payments Required on Bills: $ Telephone No.: Facsimile No.: 11. Difference: $ Total Monthly Expenses E-Mail Address: *NOTE: If you are paid weekly, multiply your weekly gross wages by 4.3 to arrive at your monthly gross wage. If you are paid every two weeks multiply your bi-weekly Mobile Tel. No.: gross wages by 2.15 to arrive at your monthly gross wage. 10. Less Total Monthly Expenses $ PLEASE ATTACH LATEST WAGE STATEMENTS SHOWING YOUR DEDUCTION American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . LIABILITIES. . . . ......... .. .................. : Total Amount To Whom Owned Type of Debt Date Index No. Incurred Plaintiff(s) -against- : : of Debt Amount Balance Due Paid to Date Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO Total Liabilities: GREETINGS: ASSETS SUMMARY (List as separately or jointly owned with spouse) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Separate Joint Joint , the Honorable Separate at the Court located at County of Total Assets Cash in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Automobiles Less Total Liabilities Bank Accounts Net Worth Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Bonds Notes Real Estates Stocks Witness, Honorable Court in County, , one of the Justices of the day of , 20 Personal Property (Attorney must sign above and type name below) Attorney(s) for Total Assets Office I certify that this statement indicates by current financial situation to the best of my knowledge. Subscribed and sworn to before me this and P.O. Address day of 20 Telephone No.: Facsimile No.: (Deputy clerk or Notary Public) E-Mail Address: Mobile Tel. No.: FD-731/Jan.02 American LegalNet, Inc. www.USCourtForms.com