Fill and Sign the Financial Statement 805 Form

IN THE CHANCERY COURT OF       COUNTY THE STATE OF MISSISSIPPI EXHIBIT "A"       PLAINTIFF       CIVIL ACTION NUMBER       DEFENDANT ********************************************************************* I. GENERAL INFORMATION NAME:       ADDRESS:       CITY, STATE AND ZIP CODE:       DATE OF BIRTH:       SOCIAL SECURITY NUMBER:       OCCUPATION:       EMPLOYER:       EMPLOYER'S ADDRESS:       NAME DATE OF BIRTH MINOR CHILDREN:                                     II. INCOME STATEMENT GROSS MONTHLY INCOME AMOUNT 1. Salary and Wages, including commissions, 1.       bonuses, allowance and overtime NOTE: To arrive at a monthly income figure if paid weekly, multiply weekly income by 4.3, if paid bi - weekly, multiply income by 2.16 2. Pensions and retirement 2.       3. Social Security 3.       4. Disability and unemployment insurance 4.       5. Public assistance (welfare, AFDC payments, 5.       etc.) 6. Dividends and interest 6.       7. Rental income 7.       8. Other income       8.       9. Other income       9.       10. TOTAL MONTHLY INCOME 10.       ITEMIZED MONTHLY DEDUCTIONS: 1. State Income Taxes 1.       2. Federal Income Taxes 2.       3. Social Security 3.       4. Mandatory Insurance 4.       5. Mandatory Retirement 5.       6. Union or other dues 6.       7. Other: (Specify) 7.       8. Other:       8.       9. TOTAL MONTHLY DEDUCTIONS 9.       10. NUMBER OF EXEMPTIONS:       10.       11. NET MONTHLY PAY 11.       III. EXPENSE STATEMENT A. LIVING EXPENSES AS OF       AS OF       Self Children Self Children 1. Rent/Mortgage                         (Residence) 2. Real Property Taxes                         3. Real Property Insurance                         4. Maintenance (Residence)                         5. Food/Household Supplies                         6. Water, Sewer, etc.                         7. Electricity                         8. Gas (Residence)                         9. Telephone                         10. Laundry & Cleaning                         11. Clothing                         12. Insurance                         (Not payroll deducted) 13. Medical                         14. Dental                         15. Child Care                         16. Children's allowance                         17. Payment of child support/alimony (Prior marriage)                         18. School Expenses                         19. Entertainment                         20. Incidentals & Miscellaneous                         21. Transportation other than vehicle                         22. Gasoline & Oil (auto)                         23. Repair (auto)                         24. Insurance (auto)                         25. Auto Payments                         26. Church donations                         27. Charitable donations                         28. Newspaper/Magazines                         29. Cable TV                         30. Pet Expenses                         31. Yard Expenses                         32. Maid                         33. Retirement (IRA etc.)                         34. Pest Control                         B. TOTAL LIVING EXPENSES: 35. Installment Payments Notes, loans, charge accounts, etc.       36.       37.       38.       39. OTHER EXPENSES:       40.       41. _       TOTAL INSTALLMENT PAYMENTS:       COMBINED TOTAL EXPENSES:       EXHIBIT "B" IV. STATEMENT OF ASSETS A. Real Estate 1. Title in the name of:       Address:       Who paid cost:       How cost paid:       Value (estimate)       Mortgage Balance       Equity       2. Title in the name of:       Address:       Who paid cost:       How cost paid:       Value (estimate)       Mortgage Balance       Equity       * List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under LIABILITIES. B. Motor Vehicles 1. Registered in the name of:       Year:       Model:       Mileage:       How cost paid:       How cost paid:       VALUE       - Loan balance       = Equity 2. Registered in the name of:       Year:       Model:       Mileage:       How cost paid:       How cost paid:       VALUE _______________ - Loan balance = Equity 3. Registered in the name of:       Year:       Model:       Mileage:       How cost paid:       How cost paid:       VALUE             - Loan balance       = Equity C. Other Personal Property (such as home computers, guns, lawnmowers, TVs, jewelry, household furnishings, etc.) VALUES                                                                         TOTAL:       D. Checking/Savings (name of Bank, Account Number and Amount in Account, including CDs, money markets, passbook accounts, etc. Name(s) on Account Bank/Account Number Type Account Balance                                                                                                 TOTAL VALUE       E. Other Investments (IRAs, stock(s), mutual funds, pension plans, etc.) Bank/Account Number Type Investment Balance                                                                                           F. Life Insurance (exclude children) Insured Company Face Amount Cash Beneficiary                                                             TOTAL CASH VALUE (less loans)       G. All Other Assets                                     TOTAL VALUE       TOTAL OF ALL ASSETS $     V. STATEMENT OF LIABILITIES (Include mortgage, car loan, credit cards, personal loans) Note : Also include under items 35-44 on Exhibit “A” A. Creditor Party Responsible Current Balance Monthly Payment Who Makes for Payment Payments 1.                               2.                               3.                               4.                               5.                               6.                               B. TOTAL LIABILITIES                               ACKNOWLEDGMENT OF TRUTHFULNESS I declare to the Court that the foregoing Exhibits “A” and “B,” including attachments, are true and correct and that this declaration was executed on the       day of       , 200       .                   Party’s Signature