[ ]Plaintiff/Petitioner, Pro Se [ ] Defendant/Respondent, Pro Se [ ]Attorney for [ ] Plaintiff/Petitioner [ ] Defendant/Respondent IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAI`I Child Support Enforcement Agency, ) FC- NO. State of Hawaii, and ) ) PATERNITY FINANCIAL SHEET [ ] Mother [ ] Father ) ) Plaintiffs/Petitioners, ) vs. ) ) ) [ ] Mother [ ] Father [ ] Caregiver ) ) [ ] Mother [ ] Father [ ] Caregiver ) ) [ ] and CHILD SUPPORT ENFORCEMENT AGENCY, ) STATE OF HAWAI`I ) ) Defendants/Respondents. ) PATERNITY FINANCIAL SHEET002 American LegalNet, Inc. www.FormsWorkFlow.com INCOME: YOU MUST LIST ALL INCOME AMOUNTS AND SOURCES GROSS MONTLY (NOTE: The Court may require you to file more detailed financial information) INCOME: 1. NAME OF PRIMARY EMPLOYER: Paid: [ ] Monthly [ ] 2 times per month [ ] every 2 weeks [ ] weekly [ ] other 2.003 OTHER INCOME:NAME OF SECOND EMPLOYER: INTEREST INCOME, name of financial institution(s) NET RENTAL INCOME, location OTHER: (i.e. social security, workers222 comp, etc.)TOTAL 3.MONEY RECEIVED FROM WELFARE BENEFITS:EXPENSES 1.003 Child care expenses paid by you, on behalf of child(ren) involved in case2.003 Medical and Dental Insurance paid for yourself $3.003 Medical and Dental Insurance paid by you for your child(ren) involved in this caseTOTAL ASSETS -List the total amounts of the following: 1.003 Credit Union/Bank/Savings Account Balances$ 2.003 Securities Values, Stocks, Bonds, etc.$ 3.003 Real Property Values$ 4.003 Personal Property (car, jewelry, etc.)$ $ $ $ $ $ $ $ $ $ $ CERTIFICATION: I declare under the penalty of law that the foregoing is true and correct. Dated: , Maui, Hawai222i, . Signature of [ ] Petitioner/Movant [ ] Defendant/Movant In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Family Court Administration Office at PHONE NO. 244-2700, FAX 244-2704 or email adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. For all Civil related matters, please call 244-2706 or visit the Service Center at 2145 Main Street, Room 141, Wailuku, HI 96793 American LegalNet, Inc. www.FormsWorkFlow.com