FINANCIAL INFORMATION STATEMENT



IN THE _____ DISTRICT COURT/COUNTY COURT AT LAW FIVEEL PASO COUNTY, TEXASIN THE MATTER OF THE MARRIAGE OF: §§ § PETITIONER,§§v.§CAUSE NO: § § RESPONDENT,§§IN THE INTEREST OF:§ § CHIL(DREN).§FINANCIAL INFORMATION STATEMENTPRESENT MONTHLY EXPENSES:HOUSING:House Payment/Rent$ _______________ Utilities (Gas, Water, Etc.$ _______________Maintenance, Repair$ _______________Insurance$ _______________TRANSPORTATION:Car Payments$ _______________Insurance$ _______________Gasoline, Oil, Maintenance, etc.$ _______________Parking, Other$ _______________Repairs$ _______________INSURANCE:Life$ _______________Health$ _______________Other$ _______________FOOD:Groceries$ _______________Restaurant Meals $ _______________PERSONAL:Work expensesLunches$ _______________Dues, fees$ _______________Medical (Not covered by insurance)Physicians/Dentists$ _______________Prescription Drugs$ _______________Clothing$ _______________Cleaning/Laundry$ _______________Grooming (Barber/Hairdresser)$ _______________Entertainment$ _______________Other $ _______________CHILDREN:Child Care$ _______________SchoolTuition$ _______________Lunches$ _______________Supplies$ _______________Medical (Not covered by insurance)Physicians/Dentist$ _______________Prescription Drugs$ _______________Clothing$ _______________Cleaning/Laundry$ _______________Grooming (Barber/Hairdresser)$ _______________Entertainment$ _______________Lessons and Activities$ _______________Allowance$ _______________Other $ _______________MISCELLANEOUS: $ _______________OTHER DEBTS: $ _______________TOTAL MONTHLY EXPENSES:$ _______________MONTHLY INCOME:PAY PERIOD:GROSS INCOME$ _______________DEDUCTIONS:Withholding Tax$ _______________F.I.C.A.$ _______________Retirement$ _______________Health, Hospitalization, Life$ _______________Insurance$ _______________Other$ _______________NET INCOME:$ _______________CURRENT CHILD SUPPORT RECEIVED:$ _______________OTHER INCOME: $ _______________TOTAL MONTHLY INCOME:$ _______________SPOUSES’S INCOME:PAY PERIOD: GROSS INCOME$ _______________DEDUCTIONS:Withholding Tax$ _______________F.I.C.A.$ _______________Retirement$ _______________Health, Hospitalization, Life$ _______________Insurance$ _______________Other $ _______________NET INCOME:$ _______________CURRENT CHILD SUPPORT RECEIVED:$ _______________OTHER INCOME: $ _______________TOTAL MONTHLY INCOME:$ _______________I CERTIFY THAT THE INCOME INCLUDED HEREIN IS TRUE AND CORRECT.DATE: PetitionerRespondent ................
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