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Fill and Sign the Hawaii Income Expense Statement Form

Fill and Sign the Hawaii Income Expense Statement Form

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STATE OF HAWAII FAMILY COURT       CIRCUIT INCOME AND EXPENSE STATEMENT for DEFENDANT CASE NUMBER       FC-D NO.       _______________________________________ PLAINTIFF (Plaintiff’s Full Name) VS. _______________________________________ DEFENDANT (Defendant’s Full Name) This document is prepared by Defendant Atty. For Defendant _______________________________________ Name _______________________________________ _______________________________________ Address _______________________________________ City, State, Zip _______________________________________ Phone Occupation: _______________________________________ _______________________________________ Job Title Employer: _______________________________________ _______________________________________ Address: _______________________________________ _______________________________________ Length of Service:       months/years. Income Tax Withholding based on:       dependants . INCOME Gross income. Paid monthly, 2 times per month, every 2 weeks, weekly, or other       Gross per pay period ………………………………….. $             Per Month ………………………. $             Payroll deductions per pay period: Fed. Income tax ……………………………… $             State income tax ……………………………… $             FICA (Social Security) ……………………… $             Union dues …………………………………… $             a) Net per pay period ……………………… $             Per month …….. $             Other: Retirement/401K………………….……… $             Credit Union……………………………… $             Direct Deposit………………………….… $             Income Assignments……………………… $             Support Payments………………………… $             Medical Insurance………………………… $             b) Take home per pay period…………… $             Per month …….. $             Other regular monthly income, (rental income, 2 nd job, interest, child support, welfare, food stamps, and any other source.) Gross monthly receipt………………….… $             Taxes paid IRS and State on above…….… $             c) Total other income net………………….….….. $             Total Monthly Income (Add per month income from lines a and c above) $             EXPENSES Do not list expenses which are paid by payroll deduction. Housing, expenses per month: Rent, mortgage, agreement of sale………………... $             Insurance if not included above …………………. $             Real Property taxes (if paid separately) …………. $             Utilities, gas, water, elec., telephone etc. ………… $             Transportation, expenses per month: Car payment, lease, rental. ………………………. $             Insurance on vehicle. ……………………………. $             Maintenance (repairs) ………………………..…. $             Operating (gas, oil & tires) ……………..………. $             Total Housing and Transportation expenses…………………………………………………….……. $             Debt service (all monthly payments, eg. credit cards, charges, finance company, personal loans) Personal Expenses per month: Self Children No. (       ) Food……………………………………………... $             $             Clothing…………………………………………. $             $             Medical and Dental .……………………………. $             $             Laundry and Cleaning. …………………………. $             $             Personal articles ………………………………... $             $             Recreation (movies, etc.) ………………………. $             $             School (include food) …………………………. $             $             Household. ………………………………..……. $             $             Bus (on monthly basis) ……………………..…. $             $             Other (                   ). ……………………. $             $             Payment to others for dependent care …………. $             $             Sub Totals ……………………………. $             Total Personal expenses ……………………………………..……. $             Grand Total expenses: Housing, Trans., Debt & personal ………………………………. $             Savings, : Income minus Expenses. ………………………………………. $             Explain in detail where savings are invested, or if there is a deficiency, who provides the funds to maintain the level of spending indicated in this income and expense statement . (Use separate sheet if more space is needed.) _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ CERTIFICATION I hereby declare under the penalty of perjury that I have supplied the information used in this Income and Expense Statement and have reviewed this statement and I certify that the information is accurate, complete and correct. DATE       DEFENDANT’S SIGNATURE

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