Approved, SCAO STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT - FAMILY DIVISION PETITION NO. COUNTY FINANCIAL STATEMENT Court address Court telephone no.1. In the matter of (name(s), alias(es), DOB) 1. Name 2. Date of birth 10. Spouse 11. Date or birth 3. Soc. sec. no. 4. Driver license no. 12. Soc. sec. no. 13. Driver license no. 5. Employers name 6. Length of 14. Employers name 15. Length of employment employment 7. Employers address 16. Employers address 8. Gross pay 9. List payroll deductions from amount at left 17. Gross pay 18. List payroll deductions from amount at left $ Federal inc. tax State inc. tax Local inc. tax $ Federal inc. tax State inc. tax Local inc. tax per FICA Other: per FICA Other: (attach W-2) (attach W-2) 19. Home address 20. Telephone no. 21. Marital status 22. Names and ages of dependents residing with petitioner single PERSONAL & EMPLOYMENT INFORMATIONmarried23. Names, ages, and relationships of all other people living in the ho me separated divorced 24. MEDICAL/MEDICAID/DENTAL/OPTICAL INSURANCES List company name and policy no., and whether group, co-deductible, et c. 25. OTHER INCOME List below all other income, including: overtime, 26. ASSETS (other than real estate and motor vehicles) tips, public assistance, child support, unemployment, veterans benefits,List all other assets below, including: checking and savings accounts, social security, pensions, workers comp., disability, interest, dividend s,stocks, bonds, insurance cash value, IRAs, deferred compensation, rent, etc. retirement funds, bond posted, etc. SOURCE OF INCOME BALANCE INSTITUTION NAME $ per Checking/Draft $ per Savings $ per Credit Union $ per ASSET VALUE $ per $ $ per $ $ per $ $ per $ $ per $ PLEASE CONTINUE ON OTHER SIDE IF NECESSARY (Item 29) PLEASE CONTINUE ON OTHER SIDE IF NECESSARY (Item 29) 27.PROPERTY REAL ESTATE MOTOR VEHICLES Purchase Price Current Value Loan Balance Payments Year Make Loan Balance Payments PLEASE CONTINUE ON OTHER SIDE JC 34 (6/03) FINANCIAL STATEMENT American LegalNet, Inc. www.USCourtForms.com>>>> 228.OTHER PAYMENTS (Do not include payroll deductions listed in items 9 and 18 or property payments listed in item 27) List all other payments, including: rent, utilities, support, loans, ga rnishments, mandatory union dues, mandatory retirement contributions, etc. ITEM PAYMENT BALANCE ITEM PAYMENT BALANCE $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ $ per $ PLEASE CONTINUE BELOW IF NECESSARY 29. EXTRA SPACE Use this space if you ran out of room above. Please label your items as INCOME, ASSETS, PROPERTY, PAYMENTS, etc.30.Attach a copy of last years Federal Income Tax Return. I declare that this financial statement has been examined by me and that its contents are true to the best of my information, knowledge,and belief. I further authorize the release of any information needed t o verify this statement or any other information needed to verifymy financial affairs. I understand that if I knowingly list any false information on this fina ncial statement, I may be found in contempt of court. Date Signature Relationship to child(ren) Date Signature Relationship to child(ren) FOR COURT USE ONLY REVIEW AND RECOMMENDATIONS: Signature American LegalNet, Inc. www.USCourtForms.com