Clear All Forms Print Income and Expenses Table of Contents Form CAFC050 - Income and Expense Statement For use in Dissolution of Marriage Cases In what Missouri County is this case to be decided? What is the case number? (This number is assigned at time of filing) In the Circuit Court of MISSOURI Case Number Division Number Information shown in blue on this form does not print. Answer all questions on this form completely. Your Information My full name is: ___________________ (First Name) ______________ (Middle Name) ________________________________ (Last Name) ________ (Jr./Sr./III) I filed this case. (I am the Petitioner) I did not file this case. (I am the Respondent) Other Party's Information The full name of my husband or wife is: ___________________ (First Name) ______________ (Middle Name) ________________________________ (Last Name) ________ (Jr./Sr./III) Monthly Income Information Form 14 Wife 1. Monthly Gross Income from Salaries, Wages and Commissions including Bonuses 2. Monthly Self-Employment Income 3. Imputed Monthly Income 4. Monthly Social Security Benefits not including Supplemental Security Income (SSI) 5. Monthly Retirement Benefits 6. Monthly Pension Income 7. Monthly Interest Income 8. Monthly Trust and Annuity Income 9. Monthly Income from Dividends and Partnership Distributions 10. Monthly Unemployment Compensation Benefits 11. Monthly Severance Pay 12. Monthly Worker's Compensation Benefits Husband ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ Statement of Income and Expenses - Page 1 of 3 Form CAFC050-07/01/2012 This form is available for free at www.selfrepresent.mo.gov American LegalNet, Inc. www.FormsWorkFlow.com Monthly Income Information (Continued) Wife 13. Monthly Disability Insurance Benefits 14. Monthly Veterans Disability Benefits 15. Monthly Military Allowances for Subsistence and Quarters 16. Husband ________________ ________________ ________________ ________________ ________________ ________________ � Line 1) Total Monthly Gross Income from Paragraphs 1 through 15 (Also enter on Form 14 ________________ ________________ These numbers are automatically calculated for you as you fill in this form. ________________ ________________ ________________ ________________ _______ ________________ ________________ ________________ ________________ _______ 17. Monthly Supplemental Security Income Benefits (SSI) 18. Monthly Payments of Temporary Assistance for Needy Families (TANF) 19. Monthly Medicaid Benefits 20. Food Stamps 21. Number of unemancipated children who are NOT the subject of this proceeding that primarily reside with each party (also enter on Form 14 � Line 2c(1)) Monthly amount of child support received pursuant to a court or administrative order for unemancipated children who are NOT the subject of this proceeding that primarily reside with each party (Also enter on Form 14 � Line 2c(3)) 22. Monthly Maintenance Received in THIS case 23. Monthly Maintenance Received in OTHER cases ________________ ________________ ________________ ________________ ________________ ________________ 24. Total Monthly court ordered maintenance being ________________ ________________ received. Add lines 22 and 23. (Form 14 � Line 1a) These numbers are automatically calculated for you as you fill in this form. Monthly Expense Information Form 14 Wife 25. Monthly court or administratively ordered child support being paid for children who are NOT the subject of this Proceeding (Form 14 � Line 2a) 26. Monthly Maintenance Paid in THIS case 27. Monthly Maintenance Paid in OTHER cases Husband ________________ ________________ ________________ ________________ ________________ ________________ 28. Total Monthly Court Ordered Maintenance being Paid. ________________ ________________ Add lines 26 and 27. (Form 14 � Line 2b) These numbers are automatically calculated for you as you fill in this form. 29. Reasonable work-related child care costs of each party Paragraph 10 for the children who are the subject of this proceeding ________________ ________________ (Form 14 � Line 6a and Line 6b) 30. Health insurance costs for the children who are the subject of this proceeding (Form 14 � Line 6c) 31. Uninsured extraordinary medical costs for the children who are the subject of this proceeding (Form 14 � Line 6d) 32. Other extraordinary child rearing costs for the children who are the subject of this proceeding (Form 14- Line 6e) 33. All Other Expenses of each person (Include housing costs, utilities, transportation costs, food, clothing, loan payments, charitable contributions, entertainment, insurance other than listed on line 30, etc.) ________________ ________________ ________________ ________________ ________________ ________________ Paragraph 5 Paragraph 9 Paragraph 14a ________________ ________________ Statement of Income and Expenses - Page 2 of 3 Form CAFC050-07/01/2012 This form is available for free at www.selfrepresent.mo.gov American LegalNet, Inc. www.FormsWorkFlow.com I certify under oath that I have given the other party a copy of this Income and Expense Statement pursuant to Supreme Court Rule 43.01(d) by: (You MUST check at least ONE of the following five boxes) Serving a copy with the original pleadings herein. Mailing a copy to the other party or his or her attorney on ____________________ (Date) at the following address: ________________________________________________________________________ (Street) _________________________ __________________ ______________ (City) (State) (Zip) Handing a copy to the other party or his or her attorney on ____________________(Date). Sending a copy to the other party or his or her attorney by fax to _______________ (fax number) on ____________________ (Date) at ____________ (Time). Sending a copy via electronic mail to the other party or his or her attorney at ____________________________________________ (Email Address) on ____________________ (Date). Instructions: The following information MUST be filled in before a notary public. This Income and Expense Statement is required to be verified before a notary public. The "Affiant" is the person that is completing