Fill and Sign the Pacses Case Number Form

Worker ID Service Type Form IN-008 07/15 Income Statement THIS FORM MUST BE FILLED OUT AND YOU MUST PROVIDE DOCUMENTS TO SUPPORT ALL AMOUNTS PROVIDED IN THIS INCOME STATEMENT (If you are self-employed or if you are salaried by a business of which you are owner in whole or in part, you must also fill out the Supplemental Income Statement which appears below.) INCOME STATEMENT OF (Name) (PACSES Number) I verify that the statements made in this Income Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. § 4904 relating to unsworn falsification to authorities. Date: Plaintiff or Defendant Please note: All correspondence must include the PACSES Case Number. ) ) ) ) ) Docket Number: PACSES Case Number: Other State ID Number: Plaintiff Defendant vs. In the Court of Common Pleas of County, Pennsylvania Phone: Fax: Other (specify) Gross Pay per Pay Period $ Itemized Payroll Deductions: Federal Withholding $ FICA Local Wage TaxState Income Tax Mandatory Retirement Union Dues Health Insurance Net Pay per Pay Period: $ Pay Period (weekly, biweekly, etc): Employer: Address:Type of Work: Payroll Number: INCOME Worker ID Service Type Form IN-008 07/15 Other Income: WeekMonth Year (Fill in Appropriate Column) Interest $ $$ Dividends Pension Distributions Total $ Other AnnuitySocial Security Rents Royalties Unemployment Comp. Workers Comp.Employer Fringe Benefits $ $$ INSURANCE TOTAL INCOME Checking accounts PROPERTY OWNED Description Value H W JOwnership* $ Company Savings accounts Policy No. Credit Union Stocks/bondsReal EstateOther H W CCoverage* Other Hospital Blue Cross Other Medical Blue Shield Health/Accident Disability Income Dental Other *H=Husband; W=Wife; J=Joint; C=Child Income Statement (Continued) PACSES Case Number: Page 2 of 3 Worker ID Service Type Form IN-008 07/15 (e) Name of accountant, controller or other person in charge of financial records: Income Statement (Continued) (1) who operates a business or practices a profession, or (2) who is a member of a partnership or joint venture, or (3) who is a shareholder in and is salaried by a closed corporation or similar entity. (b) Attach to this statement a copy of the following documents relating to the partnership, joint venture, business, profession, corporation or similar entity: (c) Name of business: Address and telephone number: (d) Nature of business (check one)(1) the most recent Federal Income Tax Return, and (2) the most recent Profit and Loss Statement. (1) partnership (2) joint venture (3) profession (4) closed corporation (5) other SUPPLEMENTAL INCOME STATEMENT (You only need to complete the below portion if you are self-employed or if you are salaried by a business of which you are owner in whole or in part) (a) This form is to be filled out by a person (check one): (3) Net income per pay period: (4) Specific deductions, if any: (f) Annual income from business: (1) How often is income received? (2) Gross income per pay period: PACSES Case Number: Page 3 of 3 Worker ID Service Type Form IN-008 07/15 Please note: All correspondence must include the PACSES Case Number. ) ) ) ) ) Docket Number: PACSES Case Number: Other State ID Number: Plaintiff Defendant vs. Guidelines Expense Statement EXPENSE STATEMENT OF (Name) (Pacses Number) I verify that the statements made in this Expense Statement are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. § 4904 relating to unsworn falsification to authorities. Date: Plaintiff or Defendant Instructions: Guidelines Expense Statement - This form should only be completed when: 1) You are requesting an adjustment to the amount of support pursuant to Rule 1910.16-5 because of unusual needs and unusual fixed obligations, other support obligations, medical expenses not covered by insurance, or any other relevant factors, or 2) You are requesting that the other party share in the following expenses pursuant to Rule 1910.16-6: child care expenses, health insurance premiums, unreimbursed medical expenses, private school tuition, summer camp, or other needs, or mortgage payment. You must provide documents to support all amounts provided in this Expense Statement In the Court of Common Pleas of County, Pennsylvania Phone: Fax: Weekly Monthly Yearly (Fill in Appropriate Column) Health Insurance Premiums Unreimbursed Medical Expenses: Doctor Dentist Orthodontist Hospital Medicine Special Needs (glasses, braces, orthopedic devices, therapy) $ $ $ Mortgage (including real estate taxes and homeowner's insurance) or Rent Worker ID Service Type Form IN-008 07/15 Guidelines Expense Statement (Continued) PACSES Case Number: Page 2 of 2 Weekly Monthly Yearly $ $ $ Parochial school Loans/Debts Support of Other Dependents: Other child support Alimony payments Other: (Specify) Child Care Private School Total