Income And Expense Statement (Without Children) {2F-E-035}

[ ]Plaintiff/Petitioner [ ] Defendant/Respondent IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAI`I ) ) ) Plaintiff/Petitioner, ) ) vs. ) ) ) ) ) Defendant/Respondent. ) FC- NO. Income and Expense Statement Occupation: Employer: Address: Income and Expense Statement [ ] Plaintiff/Petitioner [ ] Defendant/Respondent Job Title Length of service: months/years American LegalNet, Inc. www.FormsWorkFlow.com Income Tax Withholding based on: dependents Gross Income Paid: [ ] monthly [ Gross pay per period Payroll deductions per pay period: Federal income tax State income tax FICA (Social Security) Union Dues a)Net pay per periodOther: Retirement/401K Credit Union Direct Deposit Income Assignments Support Payments Medical Insurance b)Take home per pay periodINCOME ] 2 times per month [ ] every 2 weeks [ ] weekly [$ $ $ $ $ $ $ $ $ $ $ $ $ Per Month Per Month Per Month ] or other $ $ $ Other regular monthly income (rental income, 2nd job, interest, child support, welfare, food stamps and any other source) Gross monthly receipt Taxes paid IRS and State on a$ bove $ c)Total other income net$ Total Monthly Income (Add per month income from lines a and c above)$ American LegalNet, Inc. www.FormsWorkFlow.com EXPENSES002 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, elec., telephone, etc.) $ Transportation expenses per month: Car payment, lease, rental $ Insurance on vehicle $ Maintenance (repairs) $ Operating (gas, oil & tires) $ Total Housing and Transportation expenses Debt service (all monthly payments, e.g. credit cards, finance company, personal loans) Personal Expenses per month: Food Clothing Medical and Dental Laundry and Cleaning Personal articles Recreation (movies, etc.) School (include food) Household Bus (on monthly basis) Other () Payment to others for dependent care Subtotals Total Personal expenses $ $ Children No. () $ $ $ $ $ $ $ $ $ $ $ $ Self $ $ $ $ $ $ $ $ $ $ $ $ Grand Total Expenses: Housing, Transportation, Debt and Personal$002 Savings, <Deficiency>: Income minus Expenses $002 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 the information used in this and Statement and have reviewed this statement and I certify that the information is accurate, complete and correct. Date Plaintiff222s/Petitioner222s Signature Date Defendant222s/Respondent222s Signature American LegalNet, Inc. www.FormsWorkFlow.com