Financial Information Sheet - Hawaii State Judiciary
FAMILY COURT
CASE NUMBER:
FIRST JUDICIAL CIRCUIT
FINANCIAL
STATE OF HAWAI`I
INFORMATION SHEET FC-
NO.
[ ] CHILD SUPPORT ENFORCEMENT AGENCY,
This document was prepared by:
STATE OF HAWAI`I,
[ ] Petitioner
[ ] Defendant, _______________________________
_____________________________________________
[ ] MOTHER [ ] FATHER
[ ] Attorney for [ ] Petitioner [ ] Defendant
PETITIONER, vs. _____________________________________________
[ ] MOTHER [ ] FATHER [ ] CARETAKER
_____________________________________________
[ ] MOTHER [ ] FATHER [ ] CARETAKER
[ ] and CHILD SUPPORT ENFORCEMENT AGENCY, STATE OF HAWAI`I,
Name
Address
City
State
Telephone Number
Zip Code
DEFENDANT(S). INCOME: YOU MUST LIST ALL INCOME AMOUNTS AND SOURCES (Note: The Court may require you to file more detailed financial information.)
1. NAME OF PRIMARY EMPLOYER: Paid: [ ]monthly [ ]2 times per month [ ]every 2 weeks [ ]weekly [ ]other
GROSS MONTHLY INCOME $
2. OTHER INCOME: NAME OF SECOND EMPLOYER INTEREST INCOME, name of financial institution(s)
NET RENTAL INCOME, location OTHER (i.e. social security, workers comp, etc.)
$
TOTAL. . . . . . . . . . . .
$ $ $ $ 0.00
3. MONEY RECEIVED FROM WELFARE BENEFITS: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
EXPENSES
1. Child care expenses paid by you, on behalf of child(ren) involved in case . . . . . . . . . . . . . .
2. Medical and Dental Insurance paid for yourself $
3. Medical and Dental Insurance paid by you for your child(ren) involved in this case. . . . . . .
TOTAL
ASSETS (List the total amounts of the following):
1. Credit Union/Bank/Savings Account Balances .. . . . . . . . $
2. Securities Values, Stocks, Bonds, etc. . . . . . . . . . . . . . . .
$
3. Real Property Values . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
4. Personal Property (car, jewelry, etc.) . . . . . . . . . . . . . . . .
$
$
$ $ $ 0.00
CERTIFICATION: I declare under the penalty of law that the foregoing is true and
correct.
Date
Signature of [ ]Petitioner/Movant [ ]Defendant/Movant
01/2005 RG-AC-508 (1/18)
FOR COURT USE ONLY
FINANCIAL INFORMATION SHEET 1F-P-581
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