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Statement Of Income And Expenses Form. This is a Tennessee form and can be use in Williamson Local County.
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Tags: Statement Of Income And Expenses, Tennessee Local County, Williamson
IN THE _________________ COURT OF ________________ COUNTY,
TENNESSEE
__________________________,
Plaintiff,
)
)
)
)
)
)
)
vs.
__________________________,
Defendant.
No. __________________
STATEMENT OF INCOME AND EXPENSES
Comes now (Name of Party), the (Plaintiff/Defendant), who would show to the Court
as follows:
REGULAR INCOME:
A.
1.
Gross Wages and commission:
Twice Monthly____________
Weekly___________
Monthly___________
$________________
2.
Deductions each pay period:
FICA____________;
Fed. Tax__________
Other_____________
-________________
3.
B.
Net take-home earnings on a ____________ basis
Other income (from any source)
$ ________________
$ ________________
NET TAKE HOME ______________
TOTAL$________________
(Weekly/Monthly)
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He/she submits the following as an estimate of the necessary monthly expenses for
support of him/herself (and children where applicable):
A.
General Expenses:
1.
Rent or mortgage, including taxes and insurance
2.
Utilities: Water__________; Gas_____________
Elec.__________; Tel._____________
TOTAL UTILITIES
3.
4.
5.
$____________
Car Operation (gas, oil, repair, ins.)
$____________
Insurance (life and other)
$____________
Installment contracts and monthly payments:
Personal loans____________; Auto_________________
Household _______________; Other _________________
_______________________________________________
TOTAL INSTALLMENTS CONTRACTS
$____________
GENERAL EXPENSE TOTAL
B.
$____________
$____________
Other Expenses (monthly):
Myself
Children
1.
Food
____________
__________
2.
Clothing
____________
__________
3.
Medical, Dental & Drugs
____________
__________
4.
Laundry & Cleaning
____________
__________
5.
Recreation (specify)
____________
__________
6.
School expenses
____________
__________
7.
Babysitting/Other Child Care ____________
__________
8.
Beauty or Barber Shop
____________
__________
9.
Other (specify)
____________
__________
10.
Other________________
____________
__________
11.
Other________________
____________
__________
Subtotals
$____________
$__________
TOTAL
$____________
EXPENSE
$____________
(Weekly/Monthly)
NET INCOME LESS EXPENSES
$____________
I need $_____________ (Weekly/Monthly)
Under penalty of perjury, I make oath that the information set forth above is true and
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correct to the best of my knowledge.
This the _____ day of _____________, 20___.
_____________________________________
Plaintiff/Defendant
STATE OF TENNESSEE
COUNTY OF __________________
Sworn to and subscribed before me on this the ______ day of ______________,
20___.
_________________________________
Notary Public
My Commission Expires____________________
CERTIFICATE OF SERVICE
I hereby certify that a true and accurate copy of the foregoing has been furnished to
______________________ (attorney for the Plaintiff/Defendant) on this the ______ day
of ___________________, 20_____.
_______________________________
Attorney
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