Missouri > Local Circuit Courts > 32nd Circuit
Income And Expense Statement 68-H-1 - Missouri
| Income And Expense Statement Form. This is a Missouri form and can be used in 32nd Circuit Local Circuit Courts . |
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FORM 68-H-1 CIRCUIT COURT OF __________ COUNTY, MISSOURI ____________________________________ SSN: ___________________________ Petitioner, vs. ____________________________________ SSN: ___________________________ Respondent. ) ) ) ) ) ) ) ) ) ) ) Case No. ___________________ INCOME AND EXPENSE STATEMENT OF __________________________________ PETITIONER/RESPONDENT 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 Benefits, Pensions, Annuities, Bonuses, Commissions and all other sources (give monthly average and list sources of income): AVERAGE MONTHLY GROSS TOTAL WAGES, SALARY, COMMISSION, & OTHER INCOME: 3. Your share of the gross income on last year's Federal Tax Return: $__________ $__________ $__________ 1 American LegalNet, Inc. www.FormsWorkflow.com 2. ACTUAL OR ESTIMATED EXPENSES 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 G. Maintenance or Alimony H. Church and Charitable Contributions I. Other Living Expenses 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 For you $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ =========== $__________ For Children $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ =========== $__________ $__________ $__________ $__________ $__________ $__________ 2 American LegalNet, Inc. www.FormsWorkflow.com J. Day Care or Babysitter: K. All other expenses not presently identified (give a monthly average.) 1. Sundries 2. Reading material & TV 3. Gifts 4. Home Maintenance _________________________ $__________ $__________ $__________ $__________ $__________ $__________ TOTAL AVERAGE MONTHLY EXPENSES $__________ STATE OF MISSOURI County of ________________________ ) ) ) ss. Comes now ________________________________________, ("Affiant") being duly sworn on oath states that Affiant has read the foregoing Statement of Income and Expenses, and the answers given therein are true to the best of Affiant's knowledge and belief. ________________________________ Affiant Subscribed and sworn to before me on this _____________________________. ________________________________ Notary Public My Commission Expires: _____________________ 3 American LegalNet, Inc. www.FormsWorkflow.com
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