NO.______________
IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE
*
________________________________________ * N0.______________
Plaintiff(s) *
*
vs. * PART___________
*
________________________________________ *
Defendant(s) *
EXPENSE STATEMENT
This EXPENSE STATEMENT is submitted pursuant to LRCP 10.01. By signing this statement below, I hereby certify that the information contained herein is current and correct. In addition to those matters stated in my INCOME STATEMENT, applicant requests the COURT to consider further the affiant’s expenses and matters pointed out below in setting child support and/or alimony.
PART A.
I. REGULAR MONTHLY EXPENSES
a. Rent/mortgage, including taxes and insurance.............................................$____________
b. Utilities: $________(water); $________(gas);$________(electricity)$________(garbage);
$________(telephone); $________(other:____________)......................................$____________
c. Automobile: $________(monthly payment);$________(gas/oil);$________(repairs);
$________(insurance);$________(other:___________________________________)................$____________
d. Insurance (life and other, excluding auto)...... ........................................$____________
e. Installment contracts:$________(credit cards);$________(personal loans);
$________(other:________________________________________________________)................$____________
f. SUB-TOTAL REGULAR MONTHLY EXPENSES.......................................................$____________
II. OTHER MONTHLY EXPENSES
Myself Children
a. Food.....................................................$________ $________
b. Clothing.................................................$________ $________
c. Medical, dental, drugs...................................$________ $________
d. Laundry & Cleaning.......................................$________ $________
e. Recreation...............................................$________ $________
f. School expense...........................................$________ $________
g. Babysitting/child care...................................$________ $________
h. Beauty/barbershop........................................$________ $________
I. Other:________________________________________________...$________ $________
j. SUB-TOTAL OF OTHER MONTHLY EXPENSES......................$________ + $________ = $____________
TOTAL OF ALL MONTHLY EXPENSES...............................................................$____________
PART B.
I also request the COURT to consider the following as to the awarding or denying of alimony or as to the deviation from the guidelines as to child support:_____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
________________________________________ __________________________________________
[Affiant’s Social Security N0. or Tax Identification N0.] AFFIANT
SWORN TO AND SUBSCRIBED BEFORE ME THIS ____ DAY OF _____________, 20___.
My Commission expires:_____________ __________________________________________
NOTARY PUBLIC
[Form 029, Rev.2002.01.11]
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