NOTICE: This form is to be completed and a copy furnished to opposing counsel and to the Clerk of the Court prior to the hearing. All columns must be totaled. Provide past 2 years IRS returns and 2 most recent payroll stubs and if none, provide W-2 forms. FINANCIAL INFORMATION STATEMENT NO. ____________________________________________ _____________ District Court _______________________________________________ _______________________________________________ PETITIONER RESPONDENT _______________________________________________ ATTORNEY 1. 2. 3. Date of Marriage:____________________________ Ages of Children: ( ) ( )( ) ( )( WIFE $ __________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ $ __________________________ _______________________________________________ ATTORNEY Date of Separation: _______________________________ ) ( ) ( ) ( ) ( ) GROSS MONTHLY RESOURCES: Wages/Salary Overtime Bonus Commissions/Tips Interest on Savings Dividends Royalty Income Trust Income Net Rental Income Retirement/Pension Income Annuities Capital Gains Social Security Benefits Unemployment Benefits Disability/Workman's Comp. Interest on Notes Accounts Receivable Spousal Support/Alimony Other Income TOTAL RESOURCES: HUSBAND ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ $__________________________ 4. DEDUCTIONS: Withholding Tax FICA Retirement Union Dues Health Insurance Health Insurance for Children Miscellaneous TOTAL DEDUCTIONS: ($ _________________________) ( __________________________) ( __________________________) ( __________________________) ( __________________________) ( __________________________) ( __________________________) ($ _________________________) $ ($ _________________________ ) ( __________________________ ) ( __________________________ ) ( __________________________ ) ( __________________________ ) ( __________________________ ) ( __________________________ ) ($ _________________________ ) $ 5. 6. NET MONTHLY INCOME: EMPLOYMENT: WIFE ____________________________________________________________________________________________ HUSBAND________________________________________________________________________________________ WIFE IS PAID EVERY: HUSBAND IS PAID EVERY: ¨ week ¨ week ¨ two weeks ¨ two weeks ¨ bimonthly ¨ bimonthly ¨ month ¨ month Date Next Check is Received: WIFE____________________ HUSBAND_____________________ 7. QUICK ASSETS: Cash/Undeposited Checks Financial Institutions Stocks/Bonds Other WIFE $ __________________________ ___________________________ ___________________________ ___________________________ HUSBAND $__________________________ ___________________________ ___________________________ ___________________________ I can borrow $________________________________ on my signature. CIVFC11 Revised 5/29/96 2001 © American LegalNet, Inc. 8. NECESSARY MONTHLY EXPENSES: House Payment/Rent Utilities Food Doctor/Dentist/etc. Insurance Payment Car Payments Gas/Oil/Parking Car Maintenance Child Care/School Tuition Lunches/Supplies Haircuts SUBTOTAL: $ ___________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ $ ___________________ SUBTOTAL FORWARD $ ___________________ Clothing Cleaning/Laundry Legal Fees Gifts Church Support Entertainment/Activities for children Miscellaneous: _________________ _________________ _________________ TOTAL: ____________________ ____________________ ____________________ ____________________ ____________________ $ ___________________ ____________________ ____________________ ____________________ ____________________ ____________________ 9. DEBTS (OTHER THAN LISTED IN NUMBER 8 ABOVE): AMOUNT __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ TOTAL MONTHLY: $ ___________________ ____________________ ____________________ ____________________ ____________________ ____________________ MONTHLY PAYMENT $ ________________ _________________ _________________ _________________ _________________ _________________ $ ________________ +$__________________ $ 10. 11. GRAND TOTAL MONTHLY EXPENSES: (ANSWER ONLY IF YOU ANTICIPATE RECEIVING SUPPORT) I feel that the following sums are reasonably necessary or within the ability of my spouse to pay, and it will be fair and equitable to require the following: EACH PAY PERIOD a. b. For temporary alimony For child support $ ________________ + ________________ $ ________________ + ________________ $ ________________ $ ________________ ( _________________) $ ________________ MONTHLY $ ___________________ + ___________________ $ ___________________ + ___________________ $ ___________________ $ ___________________ ( ___________________ ) $ ___________________ 12. 13. 14. 15. 16. 17. 18. Total lines 11a and 11b Payee's Net Resources Total lines 12 and 13 Payor's Net Income Less Alimony and Support (line 12) Net Payor after deduction of child support and alimony (ANSWER ONLY IF YOU 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 $ ________________ + ________________ $ ________________ $ ___________________ + ___________________ $ ___________________ 19. Total lines 18a and 18b DATE:__________________________ ______________________________________________________ WIFE 'S SIGNATURE ____________