Financial Information Statement - DIVORCE

CAUSE NO. ___________________

IN THE MATTER OF

THE MARRIAGE OF

______________________

AND

______________________

AND IN THE INTEREST OF

______________________

______________________, AND

____________________,

CHILDREN

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IN THE DISTRICT COURT

______ JUDICIAL DISTRICT

__________ COUNTY, TEXAS

FINANCIAL INFORMATION STATEMENT

This statement is submitted by ____________________, (Wife/Husband).

Date of Marriage: _______________

Date of Separation: _____________

1.

Children:

___________________, Age: ________ years old

___________________, Age: ________ years old

___________________, Age: ________ years old

2.

My gross earnings from primary employment per month

Federal Income Tax

$___________

Social Security Tax

$___________

Medicare Tax

$___________

Financial Information Statement

$__________

Page 1 of 4

Medical Insurance (children only)

$___________

Medical Insurance (other family)

$___________

Dental Insurance

$___________

Vision Insurance

$___________

Life Insurance

$____________

401(k)/Retirement Deduction

$____________

Other

$____________

Total deductions

3.

$____________

My net income from other sources per month

$___________

My TOTAL net income per month

$___________

My necessary monthly living expenses:

Housing

House Mortgage/Rent

$___________

Utilities, Gas, Water, Trash

$___________

Home Phone, Cable, Internet

$___________

Maintenance/Repairs

$___________

HOA Dues

$___________

Other ________________

$___________

Transportation

Car Payment/Lease

$__________

Gasoline, Oil, Car Maintenance

$__________

Parking/Tolls

$__________

Insurance

Financial Information Statement

Page 2 of 4

Auto Insurance

$__________

Life Insurance (not deducted from my income)

$__________

Medical Insurance for children (not deducted from my income)

$__________

Medical Insurance for others (not deducted from my income)

$__________

Other ________________

$__________

Groceries

Food and Household Supplies

$__________

My personal

Work Expenses (Lunches, etc)

$__________

Uninsured medical expenses/dental expenses/drug expenses

$__________

Personal clothing

$__________

Personal cell phone

$__________

Dry Cleaning/Laundry

$__________

Grooming

$__________

Entertainment

$__________

Child support for children not the subject of this suit

$__________

Child support currently paid for the children the subject of this suit

$__________

Other _________________

$__________

Attorney¡¯s fees

Monthly Attorney's fees

$__________

Our children

Child Care

$__________

School Tuition, Fees

$__________

Financial Information Statement

Page 3 of 4

School Lunches

$__________

School Supplies

$__________

Uninsured medical expenses/dental expenses/drug expenses

$__________

Grooming

$__________

Entertainment

$__________

Sports, lessons, etc.

$__________

Cell phone

$__________

Other __________

$__________

Debt (Minimum payment per month)

_______________

$__________

_______________

$__________

_______________

$__________

_______________

$__________

TOTAL EXPENSES:

$__________

I (am/am not) requesting Temporary Spousal Support.

I request that the Court order my spouse to pay $___________ per month in Temporary Spousal

Support while this case is pending.

SIGNED on ______________________.

____________________, (Wife/ Husband)

Financial Information Statement

Page 4 of 4

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