In the Court of Common Pleas of WESTMORELAND County, Pennsylvania DOMESTIC RELATIONS SECTION 2 N MAIN ST, 3RD FLOOR, GREENSBURG, PA 15601 Phone: (724) 830-3200 Fax: (724) 830-3256 Plaintiff Name: Defendant Name: Docket Number: PACSES Case Number: Other State ID Number: Please note: All correspondence must include the PACSES Case Number. Income and Expense Statement THIS FORM MUST BE FILLED OUT (If you are self-employed or if you are salaried by a business of which you are owner in whole or part, you must also fill out the Supplemental Income Statement which appears on page two of this income and expense statement.) INCOME STATEMENT OF Section I: Income and Insurance INCOME: Employer Address Type of Work Payroll No. Gross Pay per Pay Period $ Itemized Payroll Deductions: Federal Withholding $ State Income Tax $ Credit Union $ Other Deductions (specify) Social Security Retirement Life Insurance Pay Period (wkly., bi-wkly., etc.) $ $ $ $ $ Local Wage Tax Savings Bonds Health Insurance $ $ $ $ $ Net Pay per Pay Period $ OTHER INCOME Interest Dividends Pension Annuity Social Security Rents Royalties Expense Account Gifts Unemployment Workmen’s Compensation Other Other TOTAL TOTAL INCOME Service Type (Fill in Appropriate Column) WEEK MONTH YEAR $ $ $ Ownership * PROPERTY OWNED Checking Accounts Savings Accounts Credit Union Stocks/Bonds Real Estate Other DESCRIPTION TOTAL VALUE $ H W J $ * H = Husband; W = Wife; J = Joint $ $ $ $ (monthly) American LegalNet, Inc. www.FormsWorkFlow.com Form IN-008 Worker ID Income and Expense Statement PACSES Case Number INSURANCE COMPANY POLICY# Coverage * H W C Hospital Blue Cross Other Medical Blue Shield Other Health/Accident Disability Income Dental Other * H = Husband; W = Wife; C = Child Section II: Supplemental Income Statement a. This form is to be filled out by a person (1) who operates a business or practices a profession, or (2) who is a member of a partnership or joint venture, or (3) who is a shareholder in and is salaried by a closed corporation or similar entity. b. Attach to this statement a copy of the following documents relating to the partnership, joint venture, business, profession, corporation or similar entity: (1) the most recent Federal Income Tax Return, and (2) the most recent Profit and Loss Statement c. Name of business: Address and telephone number: d. Nature of business (check one) (1) partnership (2) joint venture (3) profession (4) closed corporation (5) other e. Name of accountant, controller or other person in charge of financial records: f. Annual income from business: $ (1) How often is income received? (2) Gross income per pay period: $ (3) Net income per pay period: (4) Specified deductions, if any: $ Page 2 of 3 Service Type American LegalNet, Inc. www.FormsWorkFlow.com Form IN-008 Worker ID Income and Expense Statement PACSES Case Number Section III: Expenses Instructions: Only show extraordinary expenses in this section unless you filled out Section II on page two. The categories in BOLD FONT are especially important for calculating child support. If you are requesting Spousal Support/APL or if you assert your case cannot be determined according to the guideline grids or formula, this section must be fully completed. EXPENSES Home Mortgage/Rent Maintenance Utilities Electric Gas Oil Telephone Water Sewer Employment Public Transport. Lunch Taxes Real estate Personal Property Insurance Homeowner’s Automobile Life Accident Health Other Automobile Payments Fuel Repairs Medical Doctor Dentist Orthodontist Hospital Medicine EXPENSES (Fill in Appropriate Column) WEEK MONTH YEAR (Fill in appropriate Column) WEEK MONTH YEAR Education Private School Parochial School College Religious Personal Clothing Food Barber/Hairdresser Credit Payments Credit Card Charge Memberships Loans Credit Union $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Miscellaneous Household Help Child Care Papers/books Magazines $ $ $ $ Entertainment Pay TV Vacation Gifts Legal fees Charitable Contributions Other Child Support Alimony Payments Other $ $ Special needs (glasses, braces, orthopedic devices) Total Expenses: WEEK $ MONTH $ YEAR $ I verify that the statements made in this Income and Expense Statement are true and correct. I understand that false statements herein are subject to the criminal penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities. Date _____________________________________________________________________ Plaintiff or Defendant Page 3 of 3 Service Type American LegalNet, Inc. www.FormsWorkFlow.com Form IN-008 Worker ID