Income And Expense Statement {1F-P-081}

CASE NUMBER STATE OF HAWAI221I INCOME AND EXPENSE STATEMENT FAMILY COURT ~PlaintiffFIRST CIRCUIT (Full Name) PLAINTIFF, v. (Full Name) DEFENDANT. ~Defendant FC-D No. This document is prepared by:037 GPlaintiff GDefendant GAtty for Plaintiff GAtty for Defendant037 Name Address City, State, Zip Code Telephone No. Employer:037 Occupation (Job Title):037 Address:037 Length of Service:037 months/years. Income Tax Withholding based on: dependents. INCOME Gross income paid: Gmonthly, G2 times per month,Gevery 2weeks, Gweekly,Gor other: Gross per pay period.......................... $037 Per month....$ Payroll deductions per pay period: Fed. income tax............................. $ State income tax............................ $ FICA (Social Security)................... $ Union dues..................................... $ a) Net per pay period........................ $ Per month....$ Other: Retirement/401 K........................... $037 Credit Union................................... $037 Direct Deposit................................ $037 Income Assignments..................... $037 Support Payments......................... $037 Medical Insurance......................... $037 b) Take home per pay period............. $037 Per month.... $ Other regular monthly income (rental income, 2nd job, interest, child support, welfare, food stamps, and any other source). Gross monthly receipt.................... $037 Taxes paid IRS and State on above... $ c) Total other income net.................. $037 Per month.... $ Total Monthly Income (Add per month from lines a and c above).... $ COURT USE ONLY FC Adm 1/6/14 PAGE 1 OF 3 PAGES INCOME & EXPENSE STATEMENT 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, electricity, phone, etc... $ Transportation expenses per month:037 Car payment, lease, rental......................... $037 Insurance on vehicle.................................... $037 Maintenance (repairs).................................. $037 Operating (gas, oil & tires)........................... $037 Total Housing and Transportation $ Debt service (allmonthlypayments, e.g. credit cards, charges, finance company, personalloans).... $ Personal Expenses per month: Self Children No. ( ) Food......................................................... $ $037 Clothing.................................................... $037 $037 Medical and Dental...................................... $037 $037 Laundry & Cleaning.................................... $037 $037 Personal articles.......................................... $037 $037 Recreation (movies, etc.)............................. $037 $037 School (include food).................................. $037 $037 Household................................................... $037 $037 Bus (on monthly basis)................................ $037 $037 Other (037 )..... $ $037 Payment to others for dependent care....... $037 $ Sub-Total...................................... $037 $ Total Personal Expenses...............................................................$037 Grand Total Expenses: Housing,Transportation,Debt&Personal................................$037 Savings,<Deficiency>: Income minus Expenses.........................................................$037 FC Adm 1/6/14 PAGE 2 OF 3 PAGES INCOME & EXPENSE STATEMENT American LegalNet, Inc. www.FormsWorkFlow.com Explain in detail where savings are invested, or if there is a <deficiency>, 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 and reviewed the information used in this Income and Expense Statement and I certify that the information is accurate, complete, and correct. DATE GPLANTIFF222S GDEFENDANT222S SIGNATURE In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8303, or via email at adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions about forms or procedures. FC Adm 1/6/14 INCOME & EXPENSE STATEMENT PAGE 3 OF 3 PAGES American LegalNet, Inc. www.FormsWorkFlow.com