IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI FAMILY COURT DIVISION At Kansas City At Independence IN RE THE MARRIAGE OF: _________________________ Case No. ________________________ Petitioner, and _________________________ Respondent INCOME AND EXPENSE STATEMENT OF____________________ I. INCOME A. GROSS WAGES PER PAY PERIOD $___________ PAID : Weekly ___ Bi-Weekly ___ Semi-monthly___ Monthly ____ B. My MONTHLY Gross Wages or Salary: $ ___________ C. TAX STATUS: Single ____ Married ____ Head/household _____ Number of Dependents Claimed ________ D. PAYROLL DEDUCTIONS EACH PAY PERIOD: FICA (Social Security Tax) $_____________ Medicare $_____________ Federal Withholding Tax $_____________ State Withholding Tax $_____________ City Earnings Tax $_____________ Union dues $_____________ Health Insurance Premium $_____________ Others: $______________ ___________________________________________ ___________________________________________ ___________________________________________ My total deductions each pay period $______________ E. MY NET TAKE HOME PAY PER PAY PERIOD $_______________ F. Additional Income: (List income from second jobs, rentals, dividends, social security, retirement, V.A., business enterprises, TANF, annuities, bonuses and all other sources.) S ource I ncome ________________________________ _$_________________ __________________________________$_________________ __________________________________ $_________________ My total average monthly additional gross income $_____________ G. The value of fringe benefits paid partially or totally by employer, i.e. health, disability insurance, etc. $_____________ H. M Y TOTAL MONTHLY GROSS INCOME (Add Line B, F and G) $______________ Form 1402B Adopted 1/17/03 Effective 2/19/03 1 >>>> 2 II. ANTICIPATED MONTHLY EXPENSES A. Rent or mortgage payments (include home association dues) $___________ B. Maintenance and repairs of residence $___________ C. Utilities 1. Gas $__________ 2. Water $__________ 3. Electric $__________ 4. Telephone $___________ 5. Mobile/Cell/Pager $___________ 6. Trash Service $___________ TOTAL UTILITIES EXPENSE $___________ D. Automobiles 1. Gas and Oil $___________ 2. Maintenance $___________ 3. Tax and License $___________ 4. Payment of Loan/Lease $___________ TOTAL AUTOMOBILE EXPENSE $___________ E. Insurance 1. Life $___________ 2. Health $___________ 3. Dental $___________ 4. Vision $___________ 5. Disability $___________ 6. Homeowners/Rental (if not included in mortgage) $___________ 7. Automobile $___________ TOTAL INSURANCE EXPENSE $____________ F. Taxes 1. Real Estate (if not includ- ed in mortgage payment) $___________ 2. Personal Property $___________ TOTAL TAX EXPENSE $_____________ G. Regular monthly payments I make on debts, i.e. credit cards, etc. $____________ H. Child Support paid to other for children not in my custody and not involved in this proceeding $_____________ I. Maintenance or Alimony paid by me to persons other than my current spouse $_____________ J. Work-related Child Care (average school year and summer childcare) $_____________ Form 1402B Adopted 1/17/03 Effective 2/19/03 2 >>>> 3 K. Other Monthly Living Expenses MINE C HILDREN 1. Food $______________ $_____________ 2. Clothing $______________ $_____________ 3. Medical Care $______________ $_____________ 4. Prescription Drugs $______________ $_____________ 5. Dental Care $______________ $_____________ 6. Vision Care $______________ $_____________ 7. Recreation $______________ $_____________ 8. Barber/Beauty Shop $______________ $______________ 9. School Books $______________ $______________ 10. School Lunches $______________ $______________ 11. Sports $______________ $______________ 12. Activities $______________ $______________ 13. Tutoring $______________ $______________ 14. Lessons $______________ $______________ 15. Newspapers/Magazines $______________ $______________ 16. Church/charitable $______________ $______________ 17. Cable TV/Dish $______________ $______________ 18. Internet $______________ $______________ 19. Toiletries $______________ $______________ 20. Vacation $______________ $______________ 21. Gifts $______________ $______________ 22. Pet Expenses $______________ $______________ 23. College Expenses $______________ $______________ 24. Other Expenses ____________________ $______________ $______________ ____________________ $______________ $______________ ____________________ $______________ $______________ TOTAL OTHER EXPENSES $_____________ $______________ TOTAL AVERAGE MONTHLY EXPENSES (Add A through K) $_____________ III. MOTION TO MODIFY MAIN TENANCE OR CHILD SUPPORT A. At the date of the last Order, the gross monthly income of the other party was $_______________ B. At the date of the last Order, my gross monthly income was $_______________ C. Names and Relationships of all persons residing in my residence: _____________________________________________________ _____________________________________________________ _____________________________________________________ D. My spouse or co-habitants current monthly gross income is $________________ Form 1402B Adopted 1/17/03 Effective 2/19/03 3 >>>> 4 STATE OF MISSOURI ) ) SS. COUNTY OF ______________ ) COMES NOW ____________________________ , being of lawful age and after being duly sworn, states that the affiant has read the foregoing Statement of Income and Expenses, and that the facts therein are true and correct according to the affiants best knowledge and belief. _________________________________ AFFIANT Subscribed and sworn to before me on __________________, 2003. _________________________________ N otary Public My Commission Expires: Form 1402B Adopted 1/17/03 Effective 2/19/03 4