Fill and Sign the Expense Statement Form

REQUIRED INFORMATION TODAY’S DATE       Plaintiff/Defendant       County Domestic Relations Department Income and Expense Statement Name:       Date of Birth       SS#       Phone #       Home Address       Drivers License #       Employer       Position       Address       Phone Number       Date Employed       Other Employment       Health Insurance Company Name       Policy #       Address       Group #       1. Check Method of Payment and List Gross Income: Paid: Every 2 weeks Twice Monthly Monthly Weekly $       Gross Income 2. Subtract tax 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 ALL OTHER INCOME List any interest dividends, pensions and annuity, Social Security, net income from property, Unemployment Compensations, Workmen’s Compensation or other, such as royalties, expense accounts, gifts, etc. (if no other income check none) NONE       $                               Total Other Income       Deduct Estimated Income Taxes on such Other Income       Final Net Income Per Week $