Fill and Sign the Cv100 Income and Expense Statement Ofdot Form

OSCA (6-95) CV100 1 of 4 IN THE ________ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI Judge or Division: Case Number: In RE the Marriage of : Petitioner: SSN (last four digits): vs. Respondent: SSN (last four digits): (Date File Stamp) Income and Expense Statement of __________________________________ I. My Income A. Gross wages or salary and commissions paid to me each pay period : Paid: Weekly __________ Bi-Weekly __________ Semi-Monthly __________ Monthly ___________ B. My monthly gross wages or salary: C. My tax status claimed: Single __________ Married __________ Head/Household ___________ Number of persons claimed as deductions __________ D. Payroll deductions each pay period: FICA (social security tax) Federal withholding tax State withholding tax City earning tax Union dues Health insurance Others: (specify) My total deductions each pay period: My net take home pay each pay period: E. My take home or net pay each month: Source Amount F. My total monthly average gross additional income from all sources G. My total monthly gross income from wages (line B) and additional income (line F) H. Total gross income from my tax returns for each of the last 3 calendar years: Year Income OSCA (6-95) CV100 2 of 4 II. My Spouse’s Current Estimated Monthly Gross Income Source Amount Total III. My Anticipated Expenses (Monthly Average – Itemize) A. Rent or mortgage payments (include home association dues) B. Maintenance & repairs of residence C. Utilities 1. Gas 2. Water 3. Electricity 4. Telephone 5. Trash Service 6. Other Total Utility Expense D. Autombiles 1. Gas and oil 2. Maintenance 3. Tax and license 4. Payment of Loan 5. Other Total Automobile Expense E. Insurance 1. Life 2. Health, accident & dental 3. Disability 4. Homeowners (if not in mortgage payment) 5. Automobile 6. Other Total Insurance Expense F. Taxes 1. Real estate (if not in mortgage payment) 2. Personal property 3. Automobile 4. Other Total Tax Expense G. Payments I make on debts H. Child support I pay to others for children not in my custody and not involved in this proceeding I. Maintenance or alimony paid by me to persons other than my current spouse J. Church and charitable contributions OSCA (6-95) CV100 3 of 4 K. Other Living Expenses Mine Children in my Custody Children in Spouse’s Custody Children in Joint Custody 1. Food 2. Clothing 3. Medical care 4. Prescription drugs 5. Dental care 6. Recreation 7. Laundry and cleaning 8. Barber and beauty shop 9. School and books 10. School lunches 11. Lessons 12. Home maintenance 13. Other (itemize) Total other living expenses (total each column) L. Day care or babysitter 1. Work related 2. Non-work related Total day care/babsitter expenses (total each column) M. All other expenses not already identified (express as monthly average) 1. 2. 3. 4. 5. 6. 7. 8. 10. 11. 12. 13. 14. 15. Total all other expenses not already identified Total average monthly expenses OSCA (6-95) CV100 4 of 4 IV. Motion to Modify Information (If this statement is submitted in connection with a motion to modify maintenance or child support, complete this section) A. The date of the last order for maintenance and/or child support was B. At the date of the last order, the gross monthly income of my former spouse was C. At the date of the last order, my gross monthly income was D. Names and relationship to me of all persons residing at my residence Name Relationship E. Income each year since modification for each of the following persons Year Petitioner Petitioner’s Co-Habitant Respondent Respondent’s Co-Habitant Affidavit I certify under penalty of perjury that the above Income and Expense Statement is complete, true and accurate to the best of my knowledge and belief. ______________________________________________ Affiant Subscribed and sworn to before me, the undersigned Notary Public, on ______________________________ (date). My Commission Expires: ___________________________________________ ______________________________________________ Date Notary Public