FAMILY COURT _______ JUDICIAL CIRCUIT STATE OF HAWAI‘I CASE NUMBER: FINANCIAL INFORMATION SHEET [ ] CHILD SUPPORT ENFORCEMENT AGENCY, STATE OF HAWAI‘I, _____________________________________________ FC- NO. This document was prepared by: [ ] Petitioner [ ] Defendant, _______________________________ [ ] Attorney for [ ] Petitioner [ ] Defendant [ ] MOTHER [ ] FATHER PETITIONER, vs. _____________________________________________ [ ] M OTHER [ ] FATHER [ ] CARETAKER Name Address _____________________________________________ [ ] M OTHER [ ] FATHER [ ] CARETAKER [ ] and CHILD SUPPORT ENFORCEMENT AGENCY, STATE OF HAWAI‘I, City State Zip Code Telephone Number DEFENDANT(S). INCOME: YOU MUST LIST ALL INCOME AMOUNTS AND SOURCES (Note: The Court may require you to file more detailed financial information.) 1. 2. GROSS MONTHLY INCOME NAME OF PRIMARY EMPLOYER: Paid: [ ]monthly [ ]2 times per month [ ]every 2 weeks [ ]weekly [ ]other $ OTHER INCOME: NAME OF SECOND EMPLOYER INTEREST INCOME, name of financial institution(s) $ NET RENTAL INCOME, location OTHER (i.e. social security, workers comp, etc.) $ $ $ $ TOTAL. . . . . . . . . . . . 3. MONEY RECEIVED FROM WELFARE BENEFITS: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EXPENSES 1. Child care expenses paid by you, on behalf of child(ren) involved in case . . . . . . . . . . . . . . 2. Medical and Dental Insurance paid for yourself $ 3. Medical and Dental Insurance paid by you for your child(ren) involved in this case. . . . . . . TOTAL ASSETS (List the total amounts of the following): 1. Credit Union/Bank/Savings Account Balances .. . . . . . . . $ 2. Securities Values, Stocks, Bonds, etc. . . . . . . . . . . . . . . . $ 3. Real Property Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 4. Personal Property (car, jewelry, etc.) . . . . . . . . . . . . . . . . $ $ $ $ $ CERTIFICATION: I declare under the penalty of law that the foregoing is true and correct. Date Signature of [ ]Petitioner/Movant [ ]Defendant/Movant FOR COURT USE ONLY 01/2005 FIN AN CIAL IN FO RM AT IO N SH EET American LegalNet, Inc. www.FormsWorkflow.com