TO BE SEALED Superior-57 (revised September 2016) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT FINANCIAL STATEMENT State of Rhode Island v. Defendant Case Number Court Location Name: Age: Marital Status: M S D W Address: Number of Dependents and Ages: City and State: Telephone: Social Security Number: Employed: Y N Full - time Part - time How Long: Employer(s): Address: City and State: Monthly Income Monthly Expenses Gross Monthly Income (Self) $ $ Gross Monthly Income (Spouse) $ Mortgage or Rent $ Unemployment Benefits $ Utilities $ Social Security $ Vehicle Payments $ Retirement/Pension Benefits $ Insurance (Vehicle/Health/Life) $ Child Support $ Other Loan Payments $ Alimony $ Child Support/Alimony $ Disability $ Medical Payments $ $ Food $ Interest/Dividends $ Other: $ Other: $ Other: $ Total Income $ Total Expenses: $ Checking Balance: Real Property: Savings Balance: Other (IRA, CD, Trusts, Stocks, Bonds): I hereby certify that the information provided is truthful, complete, and accurate to the best of my knowledge. Signature of the Defendant/Parent/Guardian American LegalNet, Inc. www.FormsWorkFlow.com