Fill and Sign the Form C 58

State of Alabama Unified Judicial System Form C-58 Rev.2/79 NOTICE OF REFERENCE AND QUESTIONNAIRE Case Number IN THE________________________________________CO URT OF _____________________________________, ALABAMA (Circuit or District) (Name of County) _________________________________________________v. ____________________________________________________ Plaintiff Defendant Pursuant to an Order of Reference in the above-entitled case in the court, I have appointed and designated (date) _____________________ (time).____________. M. at my office (location) ___________________________________________ for considering the matters thereby referred to me, at which time and place all parties are to attend. Date_________________________ Clerk _____________________________________________________________ 1. Date of (Marri age) __________________________(Separation)__________________________________________________ 2. Ages of Dependent Child of this marriage: ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 3. What is the condi tion of your health? _______________________________________________________________________ 4. List any specific health needs or requirements for the minor children of this marriage. _________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. What are your necessa ry monthly living expenses? (a) Rent $ ___________________ (q) Furniture $ _________________ (b) House Payment $ _____________________ (r) Church $ ____________________ (c) Utilities: Lights $ _____________________ (s) Gifts $ ____________________ Water $ _____________________ (t) Newspaper $ ____________________ Gas $ _____________________ (u) Lunches, School $ ____________________ Telephone $ _____________________ (v) Beauty Parlor $ ____________________ (d) Food $ _____________________ (w) Haircuts $ ____________________ (e) Doctor $ _____________________ (x) Entertainment $ ____________________ (f) Dentist $ _____________________ (y) Child care $_____________________ (g) Drugs $ _____________________ (h) Life Insurance $ _____________________ (z) List all fixed credit obligations or debts owed: (i) Hospitalization $ _____________________ (j) Liability Insurance $ _____________________ Owe to whom Balance Owed Monthly Payment (k) Collision Insurance $ _____________________ ___________________ _______________ _______________ (l) Fire Insurance $ _____________________ ___________________ _______________ _______________ (m) Car Payment $ _____________________ ___________________ _______________ _______________ (n) Gasoline and Oil $ _____________________ ___________________ _______________ _______________ (o) Car Repairs $ _____________________ ___________________ _______________ _______________ (p) Other Transportation $ __________________ TOTA L________________ 6. Are you working: __________________ Ki nd of work: _____________________________ Badge No. _____________ Employer: ______________________________ Soci al Security No. ________________ Hourly rate of Pay. ________ 7. GROSS INCOME $ ________________ ฀ Weekly ฀ Monthly DEDUCTIONS: Withholding Tax $ ___________________ FICA $ ___________________ Retirement $ ___________________ Credit Union $ ___________________ Union Dues $ ___________________ _________________ $ ___________________ _________________ $ ___________________ TOTAL $ ___________________ NET INCOME ( Take Ho me Pay) $ _____________ ฀ Weekly ฀ Monthly 8. Other Income Explain: _________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ (PLEASE FILL IN AND COMPLETE BACK OF PAGE) C-58 (back) 9. Is your spouse work ing? _______________________ Kind of Work _____________________________________________ 10. GROSS INCOME $ ________________ ฀ Weekly ฀ Monthly DEDUCTIONS: Withholding Tax $ ___________________ FICA $ ___________________ Retirement $ ___________________ Credit Union $ ___________________ Union Dues $ ___________________ _________________ $ ___________________ _________________ $ ___________________ TOTAL $ ___________________ NET INCOME (Take Ho me Pay) $ ________________ ฀ Weekly ฀ Monthly 11. Other Income (Spouse): Explain: _________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 12. Physical custody and residence of Ch ildren is at present, as follows: _____________________________________________ ____________________________________________________________________________________________________ 13. The following sums are reasonably necessary, or within the ab ility of my husband to pay, and it will be fair and equitable to require the following based on his earnings and our debts: Week Month a. For Temporary Alimony $ ________________ $ ________________ b. For Child Support $ ________________ $ ________________ TOTAL $ ________________ $ ________________ 14. Wife’s Net Income $ _______________ $ _______________ TOTAL $ ________ _______ $ _______________ 15. Husband’s Net Income $ _______________ $ _______________ Less Alimony and Support $ _______________ $ _______________ Net to Husband after Deduction of Child Support and Alimony $ _______________ $ _______________ 16. (Answer only if Husband). I feet that a reasonable sum for me to pay based on my earnings and our debts: Week Month a. For Temporary Alimony $ ________________ $ ________________ b. For Child Support $ ________________ $ ________________ TOTAL $ ________________ $ ________________ I swear that these answers are true and reflect my present financial status. I understand that a false statement or answer to any question in this affidavit will subj ect me to penalties for perjury. ____________________________ ___________________________________________________ Date Affiant Sworn Before Me This Date ____________________________ ___________________________________________________ Clerk