IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE * ________________________________________ * N0.______________ PLAINTIFF * * vs. * PART___________ * ________________________________________ * DEFENDANT * INCOME STATEMENT This INCOME 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. 1. My full name is ____________________________________________________________________ : 2. My Social Security Number is : _________-______-_________ (I certify I do not have or use a different number.) 3. My Taxpayer Identification Number is: _______________________________
I do not have a number. 4. High school graduate?
NO
YES, Date of graduation: ____________________, 20___ College graduate?
NO
YES, Degree:______ ON ____________________, 20___ If no college degree, years attended:_____. Date last attended:______________20___. 5. I last worked outside the home on or about _____________, 20___. 6. Since last schooling as stated in N0. 4 above, I have worked outside the home approxi______ ymately ears. 7. For the last calendar year, the income attributable to me was $__________ (gross income) and $__________(adjusted gross income). 8. For the year before last calendar year, the income attributable to me was $________ (gross income) and $__________ (adjusted gross income). 9. I am paid:
Weekly
Every two weeks
Twice each month
Monthly
Other____________________ 10. My pay check, withot ouvertime,is $__________. 11. The following are deducted from my pay check: $_________ for federal income taxes; $_________ for social security; $__________ for Medicare; and $__________for state taxes. 12. My net pay check, without overtime,ub istr act total listed in N0. 11 from amount listed in N0. 10. 13. My net pay per month without overtime you are paid weekly, multiply N0. 12 by 4.33; if paid is $_________. [If you are 14. I have averaged $__________ per month overtime in the last 12 months. 15. If your spouse has not filed an income statement or you challenge the amount he or she allegedly makes, your best estimate as to yosurp ouses incomepe r monthis $__________. __________________________________________________ AFFIANT SWORN TO AND SUBSCRIBED BEFORE ME THIS ____ DAY OF ______________, 20___. My Commission expires: ___________, 20___. __________________________________________________ NOTARY PUBLIC [Form 034, Rev. 2002.01.11]