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Income And Expense Statement Form. This is a Missouri form and can be use in 32nd Circuit Local Circuit Courts.
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Tags: Income And Expense Statement, 68-H-1, Missouri Local Circuit Courts, 32nd Circuit
FORM 68-H-1
CIRCUIT COURT OF __________ COUNTY, MISSOURI
____________________________________
SSN: ___________________________
Petitioner,
vs.
____________________________________
SSN: ___________________________
Respondent.
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Case No. ___________________
INCOME AND EXPENSE STATEMENT OF
__________________________________
PETITIONER/RESPONDENT
Social Security Number __________________________
1.
INCOME
A.
Name and address of employer ___________________________________________
_____________________________________________________________________
Gross Wages, Salary and Commission per Pay Period
PAY PERIOD:
______Weekly ______ Bi-Weekly ______ Semi-Monthly ______ Monthly
B.
Additional Gross Income from Rentals, Dividends and Business
Enterprises, Social Security, AFDC, VA Benefits, Pensions, Annuities,
Bonuses, Commissions and all other sources (give monthly average and
list sources of income):
AVERAGE MONTHLY GROSS TOTAL WAGES, SALARY, COMMISSION,
& OTHER INCOME:
3.
$_________
Your share of the gross income on last year’s Federal Tax Return:
$__________
$__________
$__________
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2.
ACTUAL OR ESTIMATED EXPENSES stated on a MONTHLY average:
(If estimated, designate by adding “E” behind the amount)
A. Rent or mortgage payments
B. Utilities
$__________
$__________
1. Gas
2. Water
3. Electricity
4. Telephone
5. Trash Service
$__________
$__________
$__________
$__________
$__________
$__________
C. Automobiles
1. Gas and Oil
2. Maintenance (routine)
3. Taxes and Licenses
4. Payment on Auto Loan
$__________
$__________
$__________
$__________
$__________
D. Insurance
1. Life
2. Health and Accident
3. Disability
4. Homeowners
5. Automobile
$__________
$__________
$__________
$__________
$__________
$__________
E. Total payment on Installment Contracts
$__________
F. Child Support Paid to Others for Children not in your Custody
$__________
G. Maintenance or Alimony
$__________
H. Church and Charitable Contributions
$__________
I. Other Living Expenses
For you
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
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$__________
1. Food
2. Clothing
3. Medical Care
4. Prescription Drugs
5. Dental Care
6. Recreation
7. Laundry and Cleaning
8. Barber Shop
9. Beauty Shop
10. School and Books
11. Extra curricular activities
For Children
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
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$__________ $__________
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J. Day Care or Babysitter:
$__________
K. All other expenses not presently identified (give a monthly average.)
1. Sundries
2. Reading material & TV
3. Gifts
4. Home Maintenance
_________________________
$__________
$__________
$__________
$__________
$__________
TOTAL AVERAGE MONTHLY EXPENSES
$__________
STATE OF MISSOURI
County of
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________________________
ss.
Comes now ________________________________________, ("Affiant") being
duly sworn on oath states that Affiant has read the foregoing Statement of Income and
Expenses, and the answers given therein are true to the best of Affiant's knowledge and
belief.
________________________________
Affiant
Subscribed and sworn to before me on this _____________________________.
________________________________
Notary Public
My Commission Expires: _____________________
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