IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE * ________________________________________ * N0.______________ PLAINTIFF (S) * * vs. * PART___________ * ________________________________________ * DEFENDANT(S) * EXPENSE STATEMENT This EXPENSE STATEMENT is submitted pursuant to LRCP 10.02. By signing this statement below, I hereby certify that the information contained herein is current and correct. In addition to those matters stated in my INCOME STATEMENT, applicant requests the COURT to consider further the affiants expenses and matters pointed out below in setting child support and/or alimony. PART A. I. REGULAR MONTHLY EXPENSES a. Rent/mortgage, including taxes and insurance.............................................$____________ b. Utilities: $________(water); $________(gas);$________(electricity)$________(garbage); $________(telephone); $________(other:____________)......................................$____________ c. Automobile: $________(monthly payment);$________(gas/oil);$________(repairs); $________(insurance);$________(other:___________________________________)................$____________ d. Insurance (life and other, excluding auto)...... ........................................$____________ e. Installment contracts:$________(credit cards);$________(personal loans); $________(other:________________________________________________________)................$____________ f. SUB-TOTAL REGULAR MONTHLY EXPENSES.......................................................$____________ II. OTHER MONTHLY EXPENSES Myself Children a. Food.....................................................$________ $________ b. Clothing.................................................$________ $________ c. Medical, dental, drugs...................................$________ $________ d. Laundry & Cleaning.......................................$________ $________ e. Recreation...............................................$________ $________ f. School expense...........................................$________ $________ g. Babysitting/child care...................................$________ $________ h. Beauty/barbershop........................................$________ $________ I. Other:________________________________________________...$________ $________ j. SUB-TOTAL OF OTHER MONTHLY EXPENSES......................$________ + $________ = $____________ TOTAL OF ALL MONTHLY EXPENSES...............................................................$____________ PART B. I also request the COURT to consider the following as to the awarding or denying of alimony or as to the deviation fridomelin thee gus as to child support_____________________________________________________________________________________________________________________ :___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ________________________________________ __________________________________________ [Affiants Social Security N0. or Tax Identification N0.] AFFIANT SWORN TO AND SUBSCRIBED BEFORE ME THIS ____ DAY OF _____________, 20___. My Commission expires:_____________ __________________________________________ NOTARY PUBLIC [Form 029, Rev.2002.01.11]