INCOME AND EXPENSE STATEMENT NAME BUSINESS NAME ADDRESS CASE# DATE MONTH ENDING INCOME/SALES/REVENUE ______________ LESS PURCHASES: ______________ (COST OF GOODS SOLD) NET INCOME ______________ OTHER INCOME ______________ TOTAL INCOME (+) __________ EXPENSES WAGES ______________ RENT ______________ ADVERTISING ______________ BAD DEBTS ______________ GAS/OIL ______________ DEPRECIATION ______________ FREIGHT/DELIVERY ______________ INSURANCE ______________ LEGAL/ACCOUNTING ______________ SUPPLIES ______________ LICENSES ______________ TELEPHONE ______________ UTILITIES ______________ POSTAGE ______________ REPAIRS/MAINTENANCE ______________ EMPLOYMENT SECURITY______________ L&I INSURANCE ______________ DEPT OF REVENUE ______________ IRS (941) ______________ OTHER ______________ OTHER ______________ OTHER ______________ TOTAL EXPENSES (-) __________________ BUSINESS PROFIT (LOSS) ______________ Court Requirements: A. Copy of tax reports filed with tax agencies and proof of payment B. Month end account receivable balance __________________ C. Tax reserve account balance __________________________ D. Copy of 1040 ESQ (if applicable) Send to: David M. Howe 1551 Broadway, Ste 600 Tacoma, WA 98402 American LegalNet, Inc. www.USCourtForms.com