STATE OF HAWAI`I FAMILY COURT ________FIRST CIRCUIT CASE NUMBER INCOME AND EXPENSE STATEMENT u Plaintiff u Defendant u PLAINTIFF (Full Name) FC-D NO. This document is prepared by Plaintiff u Defendant u Atty. for Plaintiff u Atty. for Defendant _________________________________________________ Name _________________________________________________ VS. _________________________________________________ Address _________________________________________________ DEFENDANT (Full Name) City, State, Zip _________________________________________________ Phone Occupation: _________________________________________________________________________________ Job title Employer: __________________________________________________________________________________ Address: ___________________________________________________________________________________ Length of service: _____________ months/years. Income Tax Withholding based on: ________ dependents. INCOME Gross income. Paid: monthly, 2 times per month, every 2 weeks, weekly or other ___________ Gross per pay period ...................................... $ ___________ Payroll deductions per pay period: Per month ............................... $ ____________ 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) $ _____________ FORM NO. 073917 R12/97 INCOME & EXPENSE STATEMENT 1F-P-081 American LegalNet, Inc. www.FormsWorkflow.com 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 Food ............................................................................... $ ____________ Clothing ......................................................................... $ ____________ Medical and Dental ........................................................ $ ____________ Laundry & 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 , 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 Children No.( _ ) $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ $ ____________ u PLAINTIFF'S u DEFENDANT'S SIGNATURE FORM NO. 073917 R12/97 INCOME & EXPENSE STATEMENT 1F-P-081 American LegalNet, Inc. www.FormsWorkflow.com
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