Financial Statement Harassment {UH-02.0110}

Case Name:_____________________________ Case Number:__________________ Financial Statement - Harassment (Attachment) 1. My name is: 2. [ ] I provide support to people who live with me: How many? 3. My Monthly Income: Employed [ ] Employer's Name: Gross pay per month (salary or $ hourly pay): Take home pay per month: $ Unemployed [ ] Age(s): 6. My Monthly Household Expenses: Rent/Mortgage: Food/Household Supplies: Utilities: Transportation: $ $ $ $ 4. Other Sources of Income Per Month in my Household: Source: Source: Source: Source: $ $ $ $ Sub-Total: $ [ ] I receive food stamps. Total Income, lines 3 (take $ home pay) and 4: 5. My Household Assets: Cash on hand: Checking Account Balance: Savings Account Balance: Auto #1 (Value less loan): Auto #2 (Value less loan): Home (Value less mortgage): Other: Other: Other: Other: Other: $ $ $ $ $ $ $ $ $ $ $ Ordered Maintenance actually $ paid: Ordered Child Support actually paid: Clothing: Child Care: Education Expenses: Insurance (car, health): Medical Expenses: $ $ $ $ $ $ Sub-Total: $ 7. My Other Monthly Household Expenses: $ $ $ $ Sub-Total: $ 8. My Other Debts with Monthly Payments: $ $ $ $ Sub-Total: $ Total Household Expenses $ and Debts, lines 6, 7, and 8: Signature: /mo /mo /mo /mo Total Household Assets: $ Date: Financial Statement - Harassment (Attachment) - Page 1 of 1 UH 2.0110 (07/2011) GR 34, RCW 10.14.060 American LegalNet, Inc. www.FormsWorkFlow.com