CAUSE NO. IN THE MATTER OF IN THE DISTRICT COURT THE MARRIAGE OF AND ...

CAUSE NO. ______________________

IN THE MATTER OF THE MARRIAGE OF

AND

AND IN THE INTEREST OF

' IN THE DISTRICT COURT ' ' ' ' __________ JUDICIAL DISTRICT ' ' ' ' ______________ COUNTY, TEXAS

FINANCIAL INFORMATION STATEMENT FOR HEARINGS ON TEMPORARY ORDERS

This statement is submitted by ________________________, Husband/Wife 1. Date of marriage: 2. Date of separation: 3. Ages of children of this marriage:

Child 1

DOB:

Age:

Child 2

DOB:

Age:

Child 3

DOB:

Age:

Husband's Occupation

4. Husband's occupation:

5. Husband's gross earnings from primary employment per month

$

Health Insurance Compensation

$

Withholding/FICA

$

Insurance

$

Retirement

$

Other

$

Total deductions

$

Husband's net income from primary employment per month

$

Husband's average income from other sources per month

$

Husband's net income per month (Does Not Include Interest on Bank Accounts)

$

Wife's Occupation

6. Wife's occupation:

7 Wife's gross earnings from primary employment per month

$

Withholding/FICA

$

Insurance

$

Retirement

$

Other

$

Total deductions

$

Wife's net income from primary employment per month

$

Wife's average income from other sources per month

$

Wife's net income per month (Does Not Include Interest on Bank Accounts)

$

Necessary Monthly Living Expenses

8. Necessary monthly living expenses:

House payment or rent (Wife)

$

House payment or rent (Husband)

$

Utilities including telephone (C-Phone)

$

Food including school lunches

$

Child care

$

Car payments and auto insurance

$

Gasoline, oil, parking, bus fares, tolls, repairs

$

Uninsured medical and drug expenses

$

Uninsured dental and orthodontic expenses

$

Uninsured mental health care expenses

$

Clothing and laundry

$

Personal (entertainment, adult education, etc.)

$

Minimum monthly debt service (Credit Cards, etc.)

$

Total

$

Cash and Child's Residence

9. Funds and assets readily convertible into cash in control of Husband:

Accounts in financial institutions (banks, savings, credit unions, CDs)

$

Stocks and bonds

$

10. Funds and assets readily convertible into cash in control of Wife:

Accounts in financial institutions (banks, savings, credit unions, CDs)

$

Stocks and bonds

$

11. Children presently residing with: ___________________

12. Amount I want to receive as temporary child support

13. Amount I want to receive as temporary spousal support

Health Insurance Information

14. Health Insurance Cards/Policy attached as Exhibit A.

Insurance Carrier

Policy Number

SIGNED on

.

Husband/Wife

 ................
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