CONFIDENTIAL x-none STATE OF RHODE ISLAND ANDx-none PROVIDENCE PLANTATIONS x-none STATEMENT OF ASSETS, LIABILITIES, INCOME, AND EXPENSESx-noneFAMILY COURTx-none, S.Cx-noneCase Numberx-nonevs. x-noneName: x-noneTelephone: x-noneAddress:x-noneCity/Town, State:x-noneZip Code:x-noneEmployer:x-noneOccupation:x-noneCity/Town, State:x-noneZip Code:x-noneYesx-none x-noneNox-none x-noneSinglex-noneFamilyx-noneYesx-none x-noneNox-noneYesx-noneNo x-none1. PERSONAL INFORMATION x-noneName of Insurance Provider: x-none2. DO YOU HAVE HEALTH INSURANCE? x-noneDR-6/FINANCIAL STATEMENT x-noneNumber of Children Living With You: x-noneDo you have a dental plan? x-noneDo you have a vision plan? x-noneDefendant's Attorney/Bar Number x-nonePlaintiff x-noneDefendant x-nonePlaintiff's Attorney/Bar Number x-noneAttorney's Telephone Number x-noneName of Insurance Provider: x-noneEmployer's Telephone Number: x-noneAttorney's Telephone Number x-noneADR-6shallbefiledwithComplaintsforDivorce,BedandBoardDivorce,MiscellaneousComplaints,orChildSupportComplaints.ADR-6 shall be filed with Answers or Counterclaims or Modifications of Prior (Support) Orders. x-noneEmployer's Address: x-noneIf yes, single plan or family plan? x-noneName of Policy Holder: x-noneName of Policy Holder: x-noneName of Insurance Provider: x-noneName of Policy Holder: DR-6FC-5 (Revised November 2017) 1 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-none$x-none$x-none$x-none$ x-noneWeeklyx-noneBi-Weeklyx-noneMonthlyx-noneAnnual x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none$x-noneOther:x-none$x-noneOther:x-none$x-none$x-none$x-none$x-none$ x-noneh) Dividends x-nonei) Interest x-nonej) Trusts x-nonek) Annuities x-noned) Self-Employment (Attach a completed Schedule C from your latest tax return) x-nonee) Tips x-noneb) Overtime x-none4. GROSS INCOME FROM ALL SOURCES x-noneTOTAL LIABILITIES (From Page 8) Total Monthly Expenses (From Page 5) x-nonec) Part-Time Job x-none3. TOTAL ASSETS (From Page 7) Total Monthly Gross Income (From Page 2) x-nonel) Pensions x-noneo) Disability x-nonem) Retirement Funds x-nonen) Social Security x-nonep) Unemployment Insurance x-noney) Capital Gains x-noneg) Bonuses x-noneSubtotal: x-nonef) Commissions x-nones) Child Support x-nonea) Base Pay from Salary/Wages x-nonez) Other Income (Specify below): x-none Total Gross Income: x-noneq) Worker's Compensation x-noner) Public Assistance (welfare, etc.) x-nonev) Royalties and other rights x-nonew) Contributions from household members x-nonex) Income from S-Corps, C-Corps, LLCs, etc. x-noneu) Rental from Income Producing Property (Attach a completed Schedule A on Page 9) x-nonet) Alimony DR-6FC-5 (Revised November 2017) 2 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-noneWeeklyx-noneBi-Weeklyx-noneMonthlyx-noneAnnual x-none$x-none$x-none$x-none$x-none$x-none$ x-noneOther: x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$ x-noneOther: x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$ x-noneOther: x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$ x-noneOther: x-none x-none$x-none$x-none$x-none$x-none$ x-none5. EXPENSES (pages 3, 4, and 5) x-none1. Housing x-noneRent x-noneElectricity x-noneMortgage Payment (Principle and Interest) x-noneProperty Tax x-noneCondo Fee x-noneHome Maintenance x-noneCable Television/Internet x-noneTotal Housing: x-none2. Utilities x-noneSnow Removal/Lawn Care x-noneHeating Oil x-noneWood/Coal/Pellets x-nonePropane and Natural Gas x-noneTelephone/Cell Telephone x-noneLife x-noneWater and Sewer x-noneTrash Collection x-noneTotal Utilities: x-none3. Insurance x-noneHomeowner x-noneRenter x-noneVehicle x-noneHealth/Dental/Vision x-noneEye Care/Glasses/Contact Lenses x-nonePrescription Drugs x-noneDisability x-noneTotal Insurance: x-none4. Uninsured Health Care Expenses x-noneMedical x-noneDental x-noneOrthodontics x-noneTherapy and Counseling x-noneTotal Uninsured Health Care Expenses: DR-6FC-5 (Revised November 2017) 3 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-noneWeeklyx-noneBi-Weeklyx-noneMonthlyx-noneAnnual x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none x-none$x-noneOther:x-none x-none$x-noneOther: x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none x-none$x-none$x-none$x-none$x-none$ x-noneOther Vehicle Payments x-noneVehicle Maintenance x-none Expenses Continued to page 4 x-none5. EXPENSES (continued) x-none5. Transportation x-nonePrimary Vehicle Payment x-noneDues and Memberships x-noneVacations x-noneTobacco/Alcohol Products x-noneClothing and Shoes x-noneHair Care x-noneToiletries and Cosmetics x-noneNewspapers and Magazines x-noneEducation (personal) x-noneLaundry and Dry Cleaning x-noneGifts x-noneGas and Oil x-noneRegistration and Tax x-noneTotal Transportation: x-none6. General and Personal Expenses x-noneGroceries x-noneMeals Eaten Out or Taken Out x-nonePet Food and Care x-noneChurch and Charities x-none Total Children's Expenses and Activities: x-noneEntertainment and Recreation x-noneTotal General and Personal Expenses: x-none7. Children's Expenses and Activities x-noneChildren's Clothing x-noneDiapers x-noneDay Care x-noneSchool Supplies x-noneSchool Lunches x-noneTuition and Lessons x-noneSports and Camps DR-6FC-5 (Revised November 2017) 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-noneWeeklyx-noneBi-Weeklyx-noneMonthlyx-noneAnnualx-none$x-none$x-none$x-none$x-none$x-none$x-noneTotal Other Expenses:x-none$x-none$x-none$x-none$x-none$ x-noneNumber of exemptions: x-none$x-none$ x-noneNumber of exemptions: x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-none$x-noneOther:x-none$x-none$x-none$x-none$x-none$ x-none5. EXPENSES (continued) x-none8. Other Expenses (For example, ungarnished child support or alimony). Specify below. x-noneUnion Dues x-none Expenses Continued to page 5 x-none9. Deductions from Paycheck x-noneFederal Income Tax x-noneState Income Tax x-noneSocial Security x-noneMedicare x-noneLocal TDI x-noneState Retirement x-noneSavings x-noneTotal Financial: x-noneGarnishments x-none401(k) x-noneOther Retirement Plans x-noneLoan Payments x-noneTotal Deductions from Paycheck: x-none10. Financial x-noneIRA x-noneOther Debts DR-6FC-5 (Revised November 2017) 5 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-none$x-none$x-none$x-none$ x-noneA. Real Estate x-none- Mortgage Balance:x-noneEquity:x-none$x-none- Mortgage Balance:x-none$x-noneEquity:x-none$x-none- Mortgage Balance:x-noneEquity:x-none$x-noneTotal Real Estate Equity:x-none$x-none x-noneYearx-noneMakex-noneMarket Valuex-noneVehicle Loanx-noneEquityx-noneVehicle 1x-none$x-noneVehicle 2x-noneVehicle 3x-noneTotal:x-none$x-noneTypex-noneTotal:x-none$x-noneTotal:x-none$x-noneTotal:x-none$ x-noneDeath Benefit x-noneName x-noneE. Life Insurance: Present Cash Value x-noneValue x-none Financial Institution or Plan Names: x-noneCompany Name x-noneC. List IRA, Keough, Pension Profit Sharing, 401k, other Retirement or Financial Plans, x-noneValue x-noneD. Annuity Plan(s): x-nonePrimary Residence x-noneFair Market Value: x-noneFair Market Value: x-noneAddress: (street address, city, state, zip) x-noneReal Estate: x-noneTitle Held in Name of: x-noneB. Motor Vehicle: x-noneCompany x-noneCash Value x-none6. ASSETS x-none TOTAL EXPENSES: x-noneFair Market Value: x-noneAddress: (street address, city, state, zip) x-noneTitle Held in Name of: x-noneReal Estate: x-noneAddress: (street address, city, state, zip) x-noneTitle Held in Name of: DR-6FC-5 (Revised November 2017) 6 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL x-none6. ASSETS (continued) x-noneTot