Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Income And Expense Statement Form. This is a Missouri form and can be use in 30th Circuit Local Circuit Courts.
Loading PDF...
Tags: Income And Expense Statement, CV-100, Missouri Local Circuit Courts, 30th Circuit
IN THE ________ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI
Judge or Division:
Case Number:
In RE the Marriage of :
Petitioner:
SSN (last four digits):
vs.
Respondent:
SSN (last four digits):
(Date File Stamp)
Income and Expense Statement of __________________________________
I. My Income
A.
Gross wages or salary and commissions paid to me each pay period:
Paid: Weekly __________ Bi-Weekly __________ Semi-Monthly __________ Monthly ___________
B.
My monthly gross wages or salary:
C.
My tax status claimed: Single __________ Married __________ Head/Household ___________
Number of persons claimed as deductions __________
D.
Payroll deductions each pay period:
FICA (social security tax)
Federal withholding tax
State withholding tax
City earning tax
Union dues
Health insurance
Others: (specify)
My total deductions each pay period:
My net take home pay each pay period:
E.
My take home or net pay each month:
Amount
Source
F.
My total monthly average gross additional income from all sources
G.
My total monthly gross income from wages (line B) and additional income (line F)
H. Total gross income from my tax returns for each of the last 3 calendar years:
Year
Income
OSCA (6-95) CV100
1 of 4
American LegalNet, Inc.
www.FormsWorkFlow.com
II. My Spouse’s Current Estimated Monthly Gross Income
Source
Amount
Total
III. My Anticipated Expenses (Monthly Average – Itemize)
A.
Rent or mortgage payments (include home association dues)
B.
Maintenance & repairs of residence
C.
Utilities
1.
Gas
2.
Water
3.
Electricity
4. Telephone
5. Trash Service
6. Other
Total Utility Expense
D. Autombiles
1. Gas and oil
2. Maintenance
3. Tax and license
4. Payment of Loan
5. Other
Total Automobile Expense
E.
Insurance
1. Life
2. Health, accident & dental
3. Disability
4. Homeowners (if not in mortgage payment)
5. Automobile
6. Other
Total Insurance Expense
F.
Taxes
1.
2.
3.
4.
Real estate (if not in mortgage payment)
Personal property
Automobile
Other
Total Tax Expense
G.
Payments I make on debts
H.
Child support I pay to others 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.
Church and charitable contributions
OSCA (6-95) CV100
2 of 4
American LegalNet, Inc.
www.FormsWorkFlow.com
K.
Other Living Expenses
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Mine
Children in my
Custody
Children in
Spouse’s Custody
Children in Joint
Custody
Food
Clothing
Medical care
Prescription drugs
Dental care
Recreation
Laundry and cleaning
Barber and beauty shop
School and books
School lunches
Lessons
Home maintenance
Other (itemize)
Total other living expenses
(total each column)
L.
Day care or babysitter
1.
2.
Work related
Non-work related
Total day care/babsitter expenses
(total each column)
M. All other expenses not already identified (express as monthly average)
1.
2.
3.
4.
5.
6.
7.
8.
10.
11.
12.
13.
14.
15.
Total all other expenses not already identified
Total average monthly expenses
OSCA (6-95) CV100
3 of 4
American LegalNet, Inc.
www.FormsWorkFlow.com
IV. Motion to Modify Information
(If this statement is submitted in connection with a motion to modify maintenance or child support, complete this section)
A.
The date of the last order for maintenance and/or child support was
B.
At the date of the last order, the gross monthly income of my former spouse was
C.
At the date of the last order, my gross monthly income was
D.
Names and relationship to me of all persons residing at my residence
Name
E.
Relationship
Income each year since modification for each of the following persons
Year
Petitioner
Petitioner’s
Co-Habitant
Respondent
Respondent’s
Co-Habitant
Affidavit
I certify under penalty of perjury that the above Income and Expense Statement is complete, true and accurate to the best of my
knowledge and belief.
______________________________________________
Affiant
Subscribed and sworn to before me, the undersigned Notary Public, on ______________________________ (date).
My Commission Expires:
___________________________________________
Date
OSCA (6-95) CV100
______________________________________________
Notary Public
4 of 4
American LegalNet, Inc.
www.FormsWorkFlow.com
