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This Form is to Be Completed and a Copy Furnished to Opposing Counsel and to the Clerk of the

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This form is to be completed and a copy furnished to opposing counsel and to the clerk of the

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CIVFC11 Revised 5/29/96 NOTICE: This form is to be completed and a copy furnished to opposing counsel and to the Clerk of the Court prior to the hearing. All columns must be totaled. Provide past 2 years IRS returns and 2most recent payroll stubs and if none, provide W-2 forms. FINANCIAL INFORMATION STATEMENT NO.____________________________________________ _____________ District Court _______________________________________________ _______________________________________________ PETITIONER RESPONDENT _______________________________________________ _______________________________________________ ATTORNEY ATTORNEY 1. Date of Marriage: ____________________________ Date of Separation: _______________________________ 2. Ages of Children: ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 3. GROSS MONTHLY RESOURCES: WIFE HUSBAND Wages/Salary $ __________________________ ___________________________ Overtime ___________________________ ___________________________ Bonus ___________________________ ___________________________ Commissions/Tips ___________________________ ___________________________ Interest on Savings ___________________________ ___________________________ Dividends ___________________________ ___________________________ Royalty Income ___________________________ ___________________________ Trust Income ___________________________ ___________________________ Net Rental Income ___________________________ ___________________________ Retirement/Pension Income ___________________________ ___________________________ Annuities ___________________________ ___________________________ Capital Gains ___________________________ ___________________________ Social Security Benefits ___________________________ ___________________________ Unemployme nt Benefits ___________________________ ___________________________ Disability/Workman's Comp. ___________________________ ___________________________ Interest on Notes ___________________________ ___________________________ Accounts Receivable ___________________________ ___________________________ Spousal Support/Alimony ___________________________ ___________________________ Other Income ___________________________ ___________________________ TOTAL RESOURCES: $ __________________________ $ __________________________ 4. DEDUCTIONS: Withholding Tax ($_________________________ )($_________________________ ) FICA (__________________________ ) (__________________________ ) Retirement (__________________________ ) (__________________________ ) Union Due s (__________________________ ) (__________________________ ) Health Insurance (__________________________ ) (__________________________ ) Health Insurance for Children (__________________________ ) (__________________________ ) Miscellaneous (__________________________ ) (__________________________ ) TOTAL DEDUCTIONS: ($_________________________ )($_________________________ ) 5. NET MONTHLY INCOME: $ $ 6. EMPLOYMENT: WIFE____________________________________________________________________________________________ HUSBAND ________________________________________________________________________________________ WIFE IS PAID EVERY: ¨ week ¨ two weeks ¨ bimonthly ¨ month HUSBAND IS PAID EVERY: ¨ week ¨ two weeks ¨ bimonthly ¨ month Date Next Check is Received: WIFE____________________ HUSBAND_____________________ 7. QUICK ASSETS: WIFE HUSBAND Cash/Undeposited Checks $ __________________________ $ __________________________ Financial Institutions ___________________________ ___________________________ Stocks/Bond s ___________________________ ___________________________ Other ___________________________ ___________________________ I can borrow $________________________________ on my signature. CIVFC11 Revised 5/29/96 8. NECESSARY MONTHLY EXPENSES: House Payment/Rent $ ___________________SUBTOTAL FORWARD$ ___________________ Utilities ____________________Clothing____________________ Food ____________________Cleaning/Laundry____________________ Doctor/Dentist/etc. ____________________Legal Fees____________________ Insura nce Payment ____________________ Gifts____________________ Car Payments ____________________Church Support____________________ Gas/Oil/Parking ____________________Entertainment/Activities Car Maintenance ____________________for children____________________ Child Care/School ____________________Miscellaneous:____________________ Tuition ____________________ _________________ ____________________ Lunches/Supplies ____________________ _________________ ____________________ Haircuts ____________________ _________________ ____________________ SUBTOTAL: $ ___________________TOTAL:$ ___________________ 9. DEBTS (OTHER THAN LISTED IN NUMBER 8 ABOVE): AMOUNT MONTHLY PAYMENT __________________________ $ ___________________ $ ________________ __________________________ ____________________ _________________ __________________________ ____________________ _________________ __________________________ ____________________ _________________ __________________________ ____________________ _________________ __________________________ ____________________ _________________ TOTAL MONTHLY: $ ________________ +$__________________ 10. GRAND TOTAL MONTHLY EXPENSES: $ 11. (ANSWER ONLY IF YOU ANTICIPATE RECEIVING SUPPORT) I feel that the following sums are reasonably necessary or within the ability of my spouse to pay, and it will be fair and equitable to require the following: EACH PAY PERIOD MONTHLY a. For temporary alimony $ ________________ $ ___________________ b. For child s upport +________________ +___________________ 12. Total lines 11a and 11b $ ________________ $ ___________________ 13. Payee's Net Resources +________________ +___________________ 14. Total lines 12 and 13 $ ________________ $ ___________________ 15. Payor's Net Income $ ________________ $ ___________________ 16. Less Alimony and Support (line 12) (_________________ ) (___________________ ) 17. Net Payor after deduction of child support and alimony $ ________________ $ ___________________ 18. (ANSWER ONLY IF YOU ANTICIPATE PAYING SUPPORT) I feel that a reasonable sum for me to pay weekly or monthly would be: a. For temporary alimony $ ________________ $ ___________________ b. For child support +________________ +___________________ 19. Total lines 18a and 18b $ ________________ $ ___________________ DATE: __________________________ ______________________________________________________ WIFE 'S SIGNATURE DATE: __________________________ ______________________________________________________ HUSBAND'S SIGNATURE

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Fill and Sign the This Form is to Be Completed and a Copy Furnished to Opposing Counsel and to the Clerk of the