Fill and Sign the Blank Forms3301 C Northwestern Legal Services Pages 1 30

__________________________________ IN THE COURT OF COMMON PLEAS PLAINTIFF, ) ) ) ____________ COUNTY, PENNSYLVANIA ) v. ) CIVIL DIVISION ) ) __________________________________ ) NO. ________________ DEFENDANT ) INCOME AND EXPENSE STATEMENT OF DEFENDANT Defendant files this income and expense statement showing all income and expenses as of this date. Defendant verifies that the statements made in the income and expense statement are true and correct. Defendant understands that false statements herein are made subject to 18 PA. C.S. Section 4904 relating to unsworn falsification to authorities. Date: ____________________ ________________________________________ Defendant INCOME AND EXPENSE STATEMENT OF DEFENDANT Name: _____________________________________________________________________________ Date of Birth: _______________ SS#: _____________________ Phone No.: ______________ Home Address : ___________________________________________________________________ ___________________________________________________________________ Drivers License #: ___________________________________________________________________ Employer: ______________________________ Position: _______________________________ Address: ___________________________________________________________________________ ___________________________________________________________________________ Phone: _________________________________ Date Employed: __________________________ Other Employment: ___________________________________________________________________ Health Insurance Company Name: ______________________ Policy #: ___________________ Address: ________________________________ Group #: ______________________________ 1. GROSS INCOME$____________ 2. DEDUCTIONS Federal Income Tax $____________ Social Security $____________ State Income Tax $____________ Local Income Tax $____________ Health Insurance $____________ Union Dues $____________ Pension Contributions $____________ Credit Union $____________ Other Deductions $ ____________ Total Deductions – $____________ Subtract Totals from Gross Income $____________NET INCOME 3. OTHER INCOME (LIST) $____________ $____________ $____________ $____________ TOTAL OTHER INCOME $____________ 4. DEDUCTION FOR TAXES FROM OTHER INCOME Federal Income Tax $____________ Social Security $____________ State Income Tax $____________ Local Income Tax $____________ Health Insurance $____________ Union Dues $____________ Pension Contributions $____________ Credit Union $____________ Other Deductions $____________ Total Deductions – $____________ Subtract Totals from Gross Other Income $____________ NET OF OTHER INCOME TOTAL ALL INCOME: Weekly $____________ Monthly $____________