Fill and Sign the This Packet Assumes Both Parties Can Agree on Everything Write Form

STATE OF HAWAII FAMILY COURT CIRCUIT INCOME AND EXPENSE STATEMENT for PLAINTIFF CASE NUMBER FC-D NO. _______________________________________ PLAINTIFF (Your Full Name) VS. _______________________________________ DEFENDANT (Your Spouse’s Full Name)This document is prepared by Plaintiff Attorney For Plaintiff Atty. For Defendant_______________________________________Name______________________________________________________________________________Address_______________________________________City, State, Zip_______________________________________PhoneOccupation: ______________________________________________________________________________ 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, 2nd 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 PLAINTIFF’S SIGNATURE