NOTICE: This form is to be completed and a copy furnished to opposing Counsel and Court prior to the show cause hearing and/or hearing on the merits. All columns must be Cause No: District Court Petitioner Respondent Attorney for Petitioner 1. 2. 3. Attorney for Respondent (separation) ; ; ; ; ; Date of (marriage) Ages of children of this marriage: A. Necessary monthly Expenses: House payment/rent Utilities including telephone Food Doctor/Dentist/Drugs Insurance Premiums Car payments Gasoline/oil/parking/bus fares Car repairs/maintenance Child care/school tuition Lunches/school supplies Haircuts $ $ $ $ $ $ $ $ $ $ $ $ SUBTOTAL FORWARD Clothing Cleaning and laundry Legal Fees Gifts Church Support Entertainment Activities/lessons for children Miscellaneous (+) "A" Subtotal Total $ $ $ $ $ $ $ $ $ $ $ (+) SUBTOTAL B. Debts(other than house and car) (+) "B" Subtotal Total AMOUNT MONTHLY PAYMENT $ $ $ $ $ $ $ (+) $ $ $ (+) $ $ GRAND TOTAL (monthly expenses and debts) (3A & 3B) 4. Are you working? Name of employer: 5. 6. Yes No Kind of work: I am paid: weekly every two weeks . twice a month once a month. I will get my next check Gross Income(If available, attach last three pay stubs): EACH PAY PERIOD $ Deductions: Withholding tax FICA Retirement $ $ $ $ $ $ $ Yes No Explain: Yes No MONTHLY $ TOTAL DEDUCTIONS NET INCOME 7. 8. 9. (-) $ $ (-)$ $ Other income: Have you received any overtime pay in the last 12 months? Quick assets: $ $ $ I have or subject to my control: cash $ banks savings and loan associations stocks and bonds $ $ $ undeposited checks credit unions other I can borrow $ 10. Is your spouse working? Name of employer: Yes on my signature. No Kind of work: Revised 5/13 This form is available for download at no cost at http://www.fortbendcountytx.gov/index.aspx?page=997 totaled. FINANCIAL INFORMATION STATEMENT Financial Information Statement Form126 Revised: 2009/03 - 1 of 2 - American LegalNet, Inc. www.FormsWorkFlow.com weekly spouse's paycheck is received 12. every two weeks twice a month . once a month. My Gross Income(If available, attach last three pay stubs): EACH PAY PERIOD $ Deductions: Withholding tax FICA Retirement MONTHLY $ $ $ $ $ $ TOTAL DEDUCTIONS $ (-) $ (-)$ NET INCOME 13. Other income - - Spouse: $ Yes No Explain: $ $ 14. 15. Have you received any overtime pay in the last 12 months? Quick assets: $ $ $ Yes No My spouse has control of: cash $ stocks and bonds by signature. banks $ $ $ undeposited checks credit unions other savings and loan associations My spouse can borrow $ 16. Custody of the children is at present as follows: (ANSWER ONLY IF ANTICIPATE RECEIVING SUPPORT) The following sums are reasonably necessary or within 17. the ability of my Spouse to pay, and that it will be fair and equitable to require the following: EACH PAY PERIOD MONTHLY a. b. 18. 19. 20. 21. 22. 23. 24. For temporary alimony For child support (+) $ $ $ (+) $ $ (-) $ $ $ (+)$ $ (+)$ $ $ (-)$ $ Total lines 17a and 17b Wife's Net Income Total lines 18 and 19 Husband's Net Income Less alimony and support (line 18) Net husband after deduction of child support and alimony $ (ANSWER ONLY IF ANTICIPATE PAYING SUPPORT) I feel that a reasonable sum for me to pay weekly or monthly would be: a. b. For temporary alimony For child support (+) $ $ $ $ (+)$ $ 25. Total lines 24a and 24b DATE: Signature of Husband Wife Printed Name of FILED: Husband Wife 11. My spouse is paid: Financial Information Statement Form126 Revised: 2009/03 - 2 of 2 - American LegalNet, Inc. www.FormsWorkFlow.com