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Income And Expense Statement 1 - Missouri

Income And Expense Statement Form. This is a Missouri form and can be used in Dissolution 38th Circuit Local Circuit Courts .
 Fillable pdf Last Modified 11/13/2009
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INCOME AND EXPENSE STATEMENT OF ___________________________________________ Social Security Number 1. INCOME A. Name and address of employer Gross Wages, Salary and Commission per Pay Period $__________ PAY PERIOD: ______Weekly ______ Bi-Weekly ______ Semi-Monthly ______ Monthly B. Additional Gross Income from Rentals, Dividends and Business Enterprises, Social Security, AFDC, VA Bene- fits, Pensions, Annuities, Bonuses, Commissions and all other sources (give monthly average and list sources of income): $__________ Average Monthly Gross Total (Wages, Salary, Commission, & Additional Income) $__________ C. Your share of the gross income on last years Federal Income Tax Return: $__________ 2. Actual or estimated expenses required to mainprevitain ous standard of living stated on a MONTHLY average: (If estimated, designate by adding E behind the amount) A. Rent or mortgage payments $__________ B. Utilities 1. Gas $__________ 2. Water $__________ 3. Electricity $__________ 4. Telephone $__________ 5. Trash Service $__________ $__________ C. Automobiles 1. Gas and Oil $__________ 2. Maintenance (routine) $__________ 3. Taxes and Licenses $__________ 4. Payment on Auto Loan $__________ $__________ D. Insurance 1. Life $__________ 2. Health and Accident $__________ 3. Disability $__________ 4. Homeowners $__________ 5. Automobile $__________ $__________ E. Total payment on Installment Contracts $__________ F. Child Support Paid to Others for Children not in your Custody $__________ th 38 Circuit Form 1 (Rev. 1-1-2000) 1 <<<<<<<<<********>>>>>>>>>>>>> 2G. Maintenance or Alimony $__________ H. Church and Charitable Contributions $__________ I. Other Living Expenses For For You Children 1. Food $__________ $__________ 2. Clothing $__________ $__________ 3. Medical Care $__________ $__________ 4. Prescription Drugs $__________ $__________ 5. Dental Care $__________ $__________ 6. Recreation $__________ $__________ 7. Laundry and Cleaning $__________ $__________ 8. Barber Shop $__________ $__________ 9. Beauty Shop $__________ $__________ 10.School and Books $__________ $__________ 11.Extra curricular activities $__________ $__________ ============== ============= $__________ $__________ $__________ J. Day Care or Babysitter (Name and address of day care provider or babysitter and amount) $__________ K. All other expenses not presently identified (give as a Monthly average.) 1. Sundries $__________ 2. Reading material & TV $__________ 3. Gifts $__________ 4. Home Maintenance $__________ _________________________ $__________ TOTAL AVERAGE MONTHLY EXPENSES $__________ STATE OF MISSOURI ) )ss. County of ________________________ ) Comes now ________________________________________, ("Affiant") being duly sworn on oath states that Affiant has read the foregoing Statement of Income and Expenses, and tanswers given therein are true to the he best of Affiants knowledge and belief. ____________________________ A ffiant Subscribed and sworn to before me on this ______________________________. ( Date) ____________________________ N otary Public My Commission Expires: th 38 Circuit Form 1 (Rev. 1-1-2000) 2
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