Approved, SCAO STATE OF MICHIGAN CASE NO. FINANCIAL STATEMENT Court telephone no. Court address PERSONAL INFORMATION Name (last, first, middle) Address Date of birth house Home phone no. apartment Work phone no. lot no. Cellular phone no. City Zip Driver's license no. Mailing address (if different than above) Marital status Name and address of nearest living relative Relationship Names of dependents SSN (last 4 digits) Dates of birth Single Divorced Student (Yes/No) State Married E-mail address Separated Widowed If divorced, date final Phone no. College/University Employer 1 (Company name and address) Length of employment Employer 2 (Company name and address) Length of employment If self-employed, type of business/trade Have you ever filed for bankruptcy? If unemployed, source of support Yes No If yes, date filed General assistance Food stamps SSI AFDC Date completed ASSETS Vehicle #1 Year / Make Vehicle #2 Year / Make Bank/Financial account no. Name and address of financial institution Investment/Brokerage account no. Name and address of financial institution Other property such as real estate, boats, snowmobiles (describe) TOTAL ASSETS MONTHLY EXPENSES MONTHLY INCOME Gross monthly income (self) Gross monthly income (spouse) Unemployment benefits Social security Retirement/Pension benefits Child support Alimony/Maintenance Disability Veteran's benefits Interest/Dividends Other (cash): TOTAL INCOME $ $ $ $ $ $ $ $ $ $ $ $ Present value $ Present value $ Present balance $ Present balance $ Value $ $ Mortgage or rent Utilities Vehicle payments Insurance (vehicle/health/life) Other loan payments Child support/Alimony Medical payments Court payments Other: $ $ $ $ $ $ $ $ $ TOTAL EXPENSES $ Financial Report Authorization: I authorize the court, the court's funding unit, and their employees or agents to obtain a consumer credit report and other financial information about me from a consumer credit reporting agency or any other entity. I certify under penalty of perjury that this financial statement is a complete and accurate statement of my income, assets, and expenses, and that I have no other additional income. I will provide supporting documentation of income and debts upon request. Date MC 287 (3/09) Signature FINANCIAL STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com