Comment [COMMENT1]: This was Font/Pitch 1,10 - Off. FORM 1 Comment [COMMENT2]: This was Font/Pitch 2,10 - On. Comment [COMMENT3]: This was Font/Pitch 2,10 - Off. INCOME AND EXPENSE STATEMENT OF Comment [COMMENT4]: This was Font/Pitch 2,10 - On. Comment [COMMENT5]: This was Font/Pitch 3,10 - Off. ___________________________________________ Comment [COMMENT6]: This was Font/Pitch 2,10 - On. 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, & Additional Income) C. Your share of the gross income on last year’s Federal Income Tax Return: $__________ 2. Actual or estimated expenses required to maintain previous standard of living stated on a MONTHLY average: (If estimated, designate by adding AE@ 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 $__________ $__________ $__________ $__________ American LegalNet, Inc. www.FormsWorkFlow.com $__________ 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 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 For You Children $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ ============== ============= $__________ $__________ $__________ J. Day Care or Babysitter (Name and address of day care provider or babysitter and amount) $__________ K. All other expenses not presently identified (give as a Monthly average.) 1. Sundries 2. Reading material & TV 3. Gifts 4. Home Maintenance _________________________ TOTAL AVERAGE MONTHLY EXPENSES STATE OF MISSOURI ) )ss. County of ___________________ ) $__________ $__________ $__________ $__________ $__________ $__________ American LegalNet, Inc. www.FormsWorkFlow.com 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 ______________________________. (Date) Notary Public My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com