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Superior Court of the District of Columbia *** Multi-Door Dispute Resolution Division Family Mediation Financial Form Client's Name Case Manager's Name Mediator 1 Multi-Door Number Court Jacket Number Mediator 2 INCOME Please attach all relevant documents. Use annual income if you know it. 1Annual 1Monthly 1Twice a 1Weekly 1Bi-weekly (check one) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ month (check one) Salaries and Wages (Please attach recent pay stub and/or W-2 and tax return) Overtime (Please attach multiple pay stubs) Commissions Severance Pay Royalties Bonuses Interest and Dividends Business and Partnership Income Social Security, SSDI Veteran's Benefits Worker's Compensation Unemployment Compensation Pensions Annuities Income from Trust $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 1 American LegalNet, Inc. www.FormsWorkFlow.com Capital Gains (real and personal property transactions to the extent they represent a regular source of income) Contractual Agreements Perquisites or in-kind compensation, such as use of a company car or reimbursed meals (to the extent they are significant and represent a regular source of income or reduce living expenses, ) Income from Interest in an Estate (direct or through a Trust) Income from life insurance or endowment contracts Lottery or gambling winnings (lump sum or annuity) Prizes and awards Net Rental Income Received from Renters Other: Other: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Gross Income $ 1Annual $ 1Monthly 1Twice a $ 1Weekly 1Bi-weekly month Alimony/Spousal Support (received from any person) SSDI Derivative Benefit Payments To Children Please attach copy(ies) of current statement(s) of benefits. Child's Name Age Annual amount: $ Amount $ $ $ 2 American LegalNet, Inc. www.FormsWorkFlow.com EXPENSES for CHILDREN (not subject to this mediation) Child Support Orders (Annual amounts actually being paid pursuant to Court Order or Separation Agreement for child(ren) not subject of this mediation) Please attach copy(ies) of Court Order(s). Child's Name Age Amount of Payment Jurisdiction Order # & Date Other Child(ren) Living with Parent for Whom Parent is Legally Responsible Child's Name Age EXPENSES for CHILDREN (subject to this mediation) Medical Insurance Plan Type (check one): 1Individual 1Family For Family Policy holders only: 1) If the child(ren) subject to this mediation is/are covered by the plan, was there a cost for adding the child(ren) to the plan? No Yes Additional Cost $ If "Yes", please attach a copy of the plan description and cost for an individual policy and a family policy 2) Name of Insurance Company 3) Coverage type: HMO _____ Preferred Provider _____ Dental benefits _____ Eye care benefits _____ Prescription benefits _____ 4) Names of all individuals covered by Plan: 3 American LegalNet, Inc. www.FormsWorkFlow.com Extraordinary Medical Expenses that total more than $250 (for each child subject to this mediation, and for which you are not reimbursed) Please attach copies of bills and insurance statements. Expense Amount $ $ $ $ Annual Work / School Related Child Care Costs Please attach copies of bills or receipts for child care for child(ren) subject to this mediation. Child's Name Age Daycare $ $ $ $ Before/after school Summer camp Care $ $ $ $ $ $ $ $ Other $ $ $ $ ALIMONY/SPOUSAL SUPPORT PAID (Alimony/spousal support that is paid to other parent in this mediation) $ SWORN STATEMENT I solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the foregoing paper and that the factual statements made in it are true to the best of my personal knowledge, information and belief. Date Signature 4 American LegalNet, Inc. www.FormsWorkFlow.com 4/10/07 5 American LegalNet, Inc. www.FormsWorkFlow.com