Financial Statement {MC 287}

Approved, SCAO STATE OF MICHIGAN CASE NO. FINANCIAL STATEMENT Court address Court telephone no. PERSONAL INFORMATION Name (last, first, middle) Date of birth Social security no.Address: house apartment lot no. City Zip Home phone no. Work phone no. Cellular phone no. Drivers license no. StateMailing address (if different than above) Marital Status: single married separated widowed divorced If divorced, date finalName and address of nearest living relative Relationship Phone no. Names of dependents Date of birth Student (Yes/No) College or UniversityEmployer #1: (Company name & address) Length of Employment Employer #2: (Company name & address) Length of Employment If self-employed, type of business/trade: If unemployed, source of support: General Assistance SSI Food Stamps AFDC Have you ever filed for bankruptcy? Yes No If yes, date filed: Date completed: ASSETS Vehicle #1 Year / Make Present Value $ Vehicle #2 Year / Make Present Value $ Bank/Financial Account # Name & Address of Financial Institution Present Balance $ Bank/Financial Account # Name & Address of Financial Institution Present Balance $ Bank/Financial Account # Name & Address of Financial Institution Present Balance $ Investment/Brokerage Account # Name & Address of Financial Institution Present Balance $ Other Property such as real estate, boats, snowmobilies (describe): Value $ TOTAL ASSETS: $ MONTHLY INCOME MONTHLY EXPENSES Gross Monthly Income (self) $ Mortgage or Rent $ Gross Monthly Income (spouse) $ Utilities $ Unemployment Benefits $ Vehicle Payments $ Social Security $ Insurance (vehicle/health/life) $ Retirement/Pension Benefits $ Other Loan Payments $ Child Support $ Child Support/Alimony $ Alimony/Maintenance $ Medical Payments $ Disability $ Court Payments $ Veterans Benefits $ Other: $ Interest/Dividends $ Other (cash): $ TOTAL INCOME $ TOTAL EXPENSES$ I certify under penalty of perjury that the foregoing is a complete and accurate statement of my income, assets, and expenses, andthat I have no other additional income. I will supply supporting docume ntation of income and debts upon request. Date Signature American LegalNet, Inc.MC 287 (6/03) FINANCIAL STATEMENT www.USCourtForms.com