IN THE ___________ COURT OF __________________ COUNTY, TENNESSEE ________________________, Plaintiff, vs. ________________________, Defendant. ) ) ) ) ) ) ) No.______________ STATEMENT OF ISSUES, INCOME, PROPERTY AND EXPENSES ISSUES: The contested issues in this cause include: ________ ________ _________ _________ ________ ________ grounds for divorce care of child(ren) attorney’s fees court costs payment of debts division of property _________ alimony _________ child support _________other:_____________ 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) American LegalNet, Inc. www.USCourtForms.com NECESSARY MONTHLY EXPENSES A. General Expenses: 1. Rent or mortgage, including taxes and insurance 2. Utilities: Water__________; Gas_____________ Elec. __________; Tel._____________ Cable/Internet ________; 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): 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 $____________ NET INCOME LESS EXPENSES $____________ Myself Children ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ ____________ __________ $____________ $__________ EXPENSE $____________ (Weekly/Monthly) $____________ American LegalNet, Inc. www.USCourtForms.com PROPOSED DIVISION OF MARITAL PROPERTY Assets Value/Equity Awarded to Husband Awarded to Wife Real Estate Description: Titled: FMV: Debt: Bank Accounts/Liquid Asset Accounts Bank: Owner: Acct. #: Balance: Stocks/Mutual Funds/Other Securities Description: Market price: Retirement Description: Owner: Acct. #: Balance: Insurance Description: Policy #: Face Value: Insured: Beneficiary: CSV: American LegalNet, Inc. www.USCourtForms.com Assets Value/Equity Awarded to Husband Awarded to Wife Vehicles Make/Model/Year: Titled: FMV: Debt: Furniture Miscellaneous SEPARATE PROPERTY TO HUSBAND Description Value SEPARATE PROPERTY TO WIFE Description Value American LegalNet, Inc. www.USCourtForms.com MARITAL DEBTS OF HUSBAND Description Monthly Pymt. Balance MARITAL DEBTS OF WIFE Description Monthly Pymt. Balance SEPARATE DEBTS OF HUSBAND Description of Liability Monthly Pymt. Balance SEPARATE DEBTS OF WIFE Description Monthly Pymt. Balance This _______ day of ________________, 20____. _______________________________ Plaintiff/Defendant _______________________________ Attorney American LegalNet, Inc. www.USCourtForms.com 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 American LegalNet, Inc. www.USCourtForms.com