Affidavit Of Income And Expenses
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Affidavit Of Income And Expenses Form. This is a Illinois form and can be use in Kane Local County.
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Tags: Affidavit Of Income And Expenses, P5-D-11, Illinois Local County, Kane
IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT
KANE COUNTY, ILLINOIS
Case No.
Plaintiff/Petitioner
Defendant/Respondent
File Stamp
AFFIDAVIT OF INCOME AND EXPENSES
A. Name:
B. Date of Marriage:
C. Children of the Parties (names & ages):
D. Are parties separated?
Yes
No If yes, date of separation
E. Custodial Parent:
F. Monthly Income (if paid weekly, multiply by 52 and divide by 12 to get monthly figures):
Place of Employment:
Monthly Gross:
Federal Income Tax:
State Income Tax:
F.I.C.A.:
MED F.I.C.A.:
Other involuntary deductions:
Specify:
Voluntary deductions:
Specify:
Monthly income from other sources (specify):
Number of exemptions claimed:
Monthly Net Income:
G. Cash on hand (savings, checking, etc.):
H. Basic Household Monthly Expenses:
1. Rent or Mortgage
8. Car: Plates/Sticker/Repair
14. Food
2. House/Renters Ins.
9. Gas (car)
15. Medical/Dental
3. Real Estate Taxes
10. Car Payment
16. Clothing
4. Gas (house)
11. Car Insurance
17. Other Ins. (specify below)
5. Electric
12. Child Care
6. Water/Garbage
7. Telephone
13. Education (specify below)
18. Recreation and Travel
19. Cosmetic, Drugs,
Beauty Care
20. Other monthly creditor payments (specify creditor, balance & monthly payments):
(Enter the total of these monthly creditors payments on line 20)
Miscellaneous (specify):
(Enter the total on line 21)
20.
21.
Expense Total
Difference
STATE OF ILLINOIS COUNTY OF KANE
Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the
statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and
as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true.
Date:
Signature of Party
P5-D-11 (06/08)
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