Statement of Income and Expenses (For use in Modification Cases) Page 1 of 4 Form CAFC150 01/01/2019 This form is available for free at www.selfrepresent.mo.gov IN THE CIRCUIT COURT OF , MISSOURI (County where court is located. City of Saint Louis is considered a county.) Case (First Name) (Middle Name) (Last Name) (Jr./Sr./III)NumberPetitioner, (Enter full legal name of the person who filed the original petition)(Use number on Motion) v. Division (First Name) (Middle Name) (Last Name) (Jr./Sr./III) Number Respondent. (Enter full legal name of the person who responded to theoriginal petition) Statement of Income and Expenses (For use in Modification Cases) Statement completed by (First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Enter your full legal name above) Monthly Income Information Petitioner Respondent 1.Monthly gross income from salaries, wages andcommissions including bonuses 2.Monthly self-employment income 3.Monthly social security benefits not includingSupplemental Security Income (SSI) 4.Monthly retirement benefits 5.Monthly pension income 6.Monthly interest income 7.Monthly trust and annuity income 8.Monthly income from dividends and partnershipdistributions 9.Monthly unemployment compensation benefits 10.Monthly severance pay 11 Monthly workers compensation benefits 12.Monthly disability insurance benefits 13.Monthly veterans disability benefits American LegalNet, Inc. www.FormsWorkFlow.com Statement of Income and Expenses (For use in Modification Cases) Page 2 of 4 Form CAFC150 01/01/2019 This form is available for free at www.selfrepresent.mo.gov Monthly Income Information (Continued) Petitioner Respondent 14. Monthly military allowances for subsistence and quarters 15. Total monthly gross income. Add paragraphs 1 through 14. (Form 14 - Line 1) 16. Monthly Supplemental Security Income benefits (SSI) 17. Monthly payments of Temporary Assistance for Needy Families (TANF) 18. Monthly food stamps (SNAP) 19. Number of unemancipated children who are not the subject of this proceeding that primarily reside with each party (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 (Form 14 - Line 2c(3)) 20. Monthly maintenance received in this case 21. Monthly maintenance received in other cases 22. Total monthly court-ordered maintenance received. Add paragraphs 20 and 21. (Form 14 - Line 1a) Monthly Expense Information 23. Monthly court- or administratively-ordered child support being paid for children who are not the subject of this proceeding (Form 14 - Line 2a) 24. Monthly Maintenance a. Monthly maintenance paid in this case b. Monthly maintenance paid in other cases Total monthly court-ordered maintenance paid. Add paragraphs 24a and 24b. (Form 14 - Line 2b) 25. Reasonable monthly work-related child care costs of each party for the children who are the subject of this proceeding (Form 14 - Line 6a and Line 6b) 26. Monthly health insurance costs for the children who are the subject of this proceeding (Form 14 - Line 6c) American LegalNet, Inc. www.FormsWorkFlow.com Statement of Income and Expenses (For use in Modification Cases) Page 3 of 4 Form CAFC150 01/01/2019 This form is available for free at www.selfrepresent.mo.gov Monthly Expense Information (Continued) Petitioner Respondent 27. Monthly uninsured extraordinary medical costs for the children who are the subject of this proceeding (Form 14 - Line 6d) 28. Other monthly extraordinary child rearing costs for the children who are the subject of this proceeding (Form 14 - Line 6e) 29. All other monthly expenses of each person (Include housing costs, utilities, transportation costs, food, clothing, loan payments, charitable contributions, entertainment, insurance other than listed on line 26, etc.) 30. Total monthly expenses. Add paragraphs 23 through 29. (Do not include 24a and 24b. Use the total amounts from 24.) American LegalNet, Inc. www.FormsWorkFlow.com Statement of Income and Expenses (For use in Modification Cases) Page 4 of 4 Form CAFC150 01/01/2019 This form is available for free at www.selfrepresent.mo.gov Proof of Service on Other Parties You must send (serve) a copy of this document to each of the other parties, or their attorney(s). To obtain service, you may deliver the document by hand; send it by First Class U.S. mail, e-mail or facsimile (fax); or leave it at the office of the party222s attorney to be served with a clerk, receptionist or an attorney associated with the attorney to be served. I certify, under oath that on (date) I have sent/given a copy of this Statement of Income and Expenses (For use in Modification Cases) to each of the following parties at the address shown: Name Address: U.S. mail/e - mail/fax number Sign Below in the Presence of a Notary Public , of lawful age, being duly sworn on his or her oath, states that he or she is the person named above and that the facts stated in this Statement of Income and Expenses (For use in Modification Cases) are true according to his or her best knowledge, information and belief. (Sign above in the presence of a Notary Public) (Print your name above) The following information must be completed by a notary public. STATE OF ) ) SS COUNTY OF ) On this day of , 20 , before me personally appeared, , to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County and State aforesaid, the day and year first above written. , Notary Public County, State of Missouri My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com