Circuit Court for Name Address City or County Case No. vs. Name Address City, State, Zip City, State, Zip Telephone Telephone Plaintiff Defendant FINANCIAL STATEMENT (Child Support Guidelines) Md. Rule 9-203(b) (CC-DR-030) I, I am the Name State Relationship (for example, mother, father, aunt, grandfather, guardian, etc.) , state that: of the minor child(ren), including children who have not attained the age of 19 years old, are not married or self-supporting, and are enrolled in secondary school: Name Name Name Date of Birth Date of Birth Date of Birth Name Name Name Date of Birth Date of Birth Date of Birth The following is a list of my income and expenses (see below*): See definitions on other side before filling out. Total monthly income (before taxes) Child support I am paying for my other child(ren) each month Alimony I am paying each month to Name of Person(s) Alimony I am receiving each month from For the child or children listed above: The monthly health insurance premium Work-related monthly child care expenses Extraordinary monthly medical expenses School and transportation expenses Name of Person(s) *To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3 and yearly expenses should be divided by 12. If you do not pay the same amount each month for any of the categories listed, figure what your average monthly expense is. I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information, and belief. Date Signature CC-DR-030 (Rev. 04/2016) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Total Monthly Income: Include income from all sources including self-employment, rent, royalties, business income, salaries, wages, commissions, bonuses, dividends, pensions, interest, trusts, annuities, social security benefits, workers compensation, unemployment benefits, disability benefits, alimony or maintenance received, tips, income from side jobs, severance pay, capital gains, gifts, prizes, lottery winnings, etc. Do not report benefits from means-tested public assistance programs such as food stamps or AFDC. Extraordinary Medical Expenses: Uninsured expenses over $100 for a single illness or condition including orthodontia, dental treatment, asthma treatment, physical therapy, treatment for any chronic health problems, and professional counseling or psychiatric therapy for diagnosed mental disorders. Child Care Expenses: Actual child care expenses incurred on behalf of a child due to employment or job search of either parent with amount to be determined by actual experience or the level required to provide quality care from a licensed source. School and Transportation Expenses: Any expenses for attending a special or private elementary or secondary school to meet the particular needs of the child and expenses for transportation of the child between the homes of the parents. CC-DR-030 (Rev. 04/2016) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com