Interim Monthly Income And Expense Statement {4A-212}

4A-212. Interim monthly income and expenses statement. [For use with Rule 1-122 NMRA] STATE OF NEW MEXICO COUNTY OF ___________________________ ___________________ JUDICIAL DISTRICT _________________________________________, Petitioner, v. _________________________________________, Respondent. SERVE THIS FORM ON THE OTHER PARTY. DO NOT FILE WITH THE COURT. INTERIM MONTHLY INCOME AND EXPENSES STATEMENT1 (fixed percentage for child expenses) STATE OF NEW MEXICO COUNTY OF _____________ ) ) ss. ) No. __________ I, ___________________(Petitioner) (Respondent), state under penalty of perjury that the following is true and correct at this time: Petitioner Column 1 1. Gross monthly income2 a. Gross monthly wages b. Rental income c. Self-employment income d. Dividends and interest e. Other income Total gross monthly income Payroll deductions3 a. Federal withholding b. State withholding c. Estimated tax payments d. FICA Respondent Combined Column 2 Column 3 $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ 2. 3. $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ American LegalNet, Inc. www.FormsWorkFlow.com e. f. g. h. i. j. 4. Medicare Health insurance Life and disability insurance Union dues Mandatory retirement Other_____________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ Total payroll deductions (Add items in #3) Net monthly income (Subtract Line 4 from Line 2) Monthly fixed expenses4: a. Residence5 b. Utilities6 c. Car payments d. Insurance premiums (1) Car or other vehicle (2) Life7 (3) Health7 (4) Homeowners8 or renters (5) Other e. Day care9 f. Credit card payments10 g. Loan payments h. Child support payments11 i. Medical j. Other ___________ Total monthly fixed expenses (Add items in #6 and #7)12 Net spendable income (Line 5 minus Line 7) 1/2 of combined net spendable income (1/2 of Line 8 Column 3)13 Amount transferred and received14 Child support adjustment15 (see table, Use Note 15) Total to be transferred16 5. $_________ $_________ $_________ 6. $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ $_________ 7. 8. $_________ $_________ $_________ 9. $_________ $_________ $_________ $_________ $_________ $_________ 10. 11. 12. $_________ $_________ American LegalNet, Inc. www.FormsWorkFlow.com I, _______________________, affirm under penalty of perjury under the laws of the State of New Mexico that I am the [ ] Petitioner (or) [ ] Respondent in the above-entitled cause, and I know and understand that the contents of this Statement are true to the best of my knowledge and belief. ___________________________________ Signature Date USE NOTE 1. This form is to be used with an Interim Order Allocating Income and Expenses, Form 4A-213 NMRA. Unless, upon motion of a party, the court orders the division of separate income and expenses, only community income and expenses should be included on this form. In minimal or negative income cases, the court will have discretion to fashion an appropriate order. 2. "Gross monthly income" is income from all sources except child support received from a prior court order. For self-employed individuals, gross monthly income means gross receipts less reasonable and ordinary business expenses. For varying income and expenses use the average of the last three (3) months' income and expenses. Gross monthly income is to be computed by using one of the following: hourly wage x average hours worked per week x 52 divided by 12; weekly wage x 52 divided by 12; every two weeks wage x 26 divided by 12; twice monthly x 2. For varying wages, use the average of the last three months' income. 3. "Deductions" are payroll deductions for taxes, social security, health insurance, union dues, retirement and other employer-related deductions. Payroll deductions are to be computed on a monthly basis as described in Use Note 2. 4. "Monthly fixed expenses" include periodic expenses even though paid quarterly, semiannually or yearly. Fixed expenses are to be computed on a monthly basis by using one of the following: annual income or expenses divided by 12. For varying expenses, use the average of the last three months' receipts or expenses. 5. Residence fixed expense is mortgage or rent actually paid. If a party receives free rent, e.g., by living with parents, that party's rent is imputed as zero. If residence expense is a mortgage payment for the residence of a party, unless already separately stated, include insurance and taxes. 6. Include monthly average payments for gas, electricity, water, sewer, refuse, and basic telephone bill, if not paid as part of rent. Use average for last 12 months if known. 7. Do not include medical, dental, liability, life, or other insurance that is deducted by payroll deduction. 8. Do not include homeowners insurance premiums if the premium is included as part of the residence expense, Line 6(a). 9. Day care fixed expense is work-related day care and does not include baby-sitting or occasional day care. 10. "Credit card payments" is listed as a fixed expense and includes only the minimum monthly payment as of the date of the filing of the petition. 11. Any regular monthly payment ordered by a prior order of child support or alimony, which is actually paid, is a fixed expense. American LegalNet, Inc. www.FormsWorkFlow.com 12. Line 8. "Net spendable income" and "combined net spendable income" are determined by subtracting Line 7, "total monthly fixed expenses," from Line 5, "net monthly income." Negative combined net spendable income. If the "combined net spendable income" (Line 8, Column 3) is a negative number, and there are no children, adjust the allocations of income or