SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION FINANCIAL STATEMENT In re Estate of _________________________________________, minor NAME: NAME AND ADDRESS OF CURRENT EMPLOYER: INCOME INFORMATION * 1. 2. Monthly gross wages ....................... Less Mandatory Monthly Deductions: Federal Income Tax ........... $________ State Income Tax ............. $________ Retirement: FICA ................................ $________ Social Security .................. $________ Medical Insurance ................. $________ Other .................................. $________ TOTAL ................................. $________ Monthly Net Wages ................................ (Subtract Line 2 from Line 1) Monthly income from all other sources (e.g., part-time or overtime wages, fees, rents, dividends, commissions, unemployment compensation, disability, social security, retirement, interest, bonuses, etc.) ...................................... Less Other Mandatory Monthly Deductions: Federal Income Tax ........... $________ State Income Tax ............. $________ Retirement: FICA ................................ $________ Social Security .................. $________ Medical Insurance ................. $________ Other .................................. $________ TOTAL ................................. $________ Monthly Net Income from All other sources (Subtract Line 5 from Line 4) Total Monthly Net Disposable Income $ __________ $ __________ __________ GDN ______ OCCUPATION: I claim ________ exemptions for withholding tax purposes. AVERAGE MONTHLY EXPENSES Wife/Husband Children Housing, etc. Rent/Mortgages .......... Utilities ...................... Taxes ........................ Food Groceries/Household Supplies ..................... Meals Out ................... Automobile Payment .................... Gas/Oil ...................... Repairs ...................... Insurance ................... Tags .......................... Life Insurance (List Beneficiaries) ____________________ ____________________ ____________________ $ ___________ ___________ ___________ $ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 3. 4. $ __________ Health Insurance (not listed as income deduction) School Tuition Supplies/Fees Child Care Expenses To allow for employment/education To allow for recreation Lesson (e.g. music, dance, art) Allowance Clothing/Uniforms Dry Cleaning/Laundry Medical Expenses (Unpaid by Insurance) Charitable Contributions Recreation Vacations Miscellaneous: ____________________ ____________________ ____________________ Period Payments Required on Bills: ____________________ ____________________ ____________________ Total Monthly Expenses ___________ ___________ 5. ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ 6. $ __________ 7. $ __________ 8. Total Monthly Gross Income .................... (Add Lines 1 and 4) SUMMARY Total Monthly Net Disposable Income (line 7) $ __________ 9. $ __________ $ __________ $ __________ 10. Less Total Monthly Expenses 11. Difference ............................................ ___________ ___________ ___________ ___________ ___________ ___________ ___________ ___________ * NOTE: If you are paid weekly, multiply your weekly gross wages by 4.3 to arrive at your monthly gross wages. If you are paid every two weeks, multiply your bi-weekly gross wages by 2.15 to arrive at your monthly gross wage. American LegalNet, Inc. www.FormsWorkFlow.com LIABILITIES Type of Debt To Whom Owed Date Incurred Total Amount of Debt Amount Paid to Date Balance Due Total Liabilities: ASSETS (List as separately or jointly owned) Separate Joint SUMMARY Separate Joint Cash Automobiles Bank Accounts Bonds Notes Real Estate Stocks Personal Property Total Assets Less Total Liabilities Net Worth Total Assets I, __________________________, being first duly sworn, on oath, depose and say that I have read the foregoing financial statement and that the facts therein stated indicate my current financial situation to the best of my knowledge, information, and belief. __________________________________________ (Signature) Subscribed and sworn before me this ________ day of _________________________, 20_____ __________________________________________ (Deputy Clerk or Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com