Free Financial Statement - Michigan

Approved, SCAO

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY
Court address

FINANCIAL STATEMENT

CASE NO. PETITION NO.

Court telephone no.

1. In the matter of
(name(s), alias(es), DOB)

PERSONAL & EMPLOYMENT INFORMATION

1. Name 3. Soc. sec. no. 5. Employer's name 7. Employer's address 8. Gross pay $

2. Date of birth 4. Driver license no. 6. Length of employment

10. Spouse 12. Soc. sec. no. 14. Employer's name 16. Employer's address 17. Gross pay $ per (attach W-2)

11. Date or birth 13. Driver license no. 15. Length of employment

9. List payroll deductions from amount at left Federal inc. tax State inc. tax Local inc. tax Other:

18. List payroll deductions from amount at left Federal inc. tax State inc. tax Local inc. tax FICA Other: 20. Telephone no.

per FICA (attach W-2) 19. Home address

21. Marital status 22. Names and ages of dependents residing with petitioner single married 23. Names, ages, and relationships of all other people living in the home separated divorced 24. MEDICAL/MEDICAID/DENTAL/OPTICAL INSURANCES List company name and policy no., and whether group, co-deductible, etc.

25. OTHER INCOME List below all other income, including: overtime, tips, public assistance, child support, unemployment, veteran's benefits, social security, pensions, workers comp., disability, interest, dividends, rent, etc. SOURCE OF INCOME $ $ $ $ $ $ $ $ $ per per per per per per per per per

26. ASSETS (other than real estate and motor vehicles) List all other assets below, including: checking and savings accounts, stocks, bonds, insurance cash value, IRA's, deferred compensation, retirement funds, bond posted, etc. BALANCE INSTITUTION NAME Checking/Draft Savings Credit Union ASSET $ $ $ $ $ PLEASE CONTINUE ON OTHER SIDE IF NECESSARY (Item 29) MOTOR VEHICLES Year Make Loan Balance Payments VALUE

PLEASE CONTINUE ON OTHER SIDE IF NECESSARY (Item 29) 27.PROPERTY REAL ESTATE Purchase Price Current Value Loan Balance Payments

PLEASE CONTINUE ON OTHER SIDE
JC 34 (6/03)

FINANCIAL STATEMENT

28.OTHER PAYMENTS (Do not include payroll deductions listed in items 9 and 18 or property payments listed in item 27) List all other payments, including: rent, utilities, support, loans, garnishments, mandatory union dues, mandatory retirement contributions, etc. ITEM PAYMENT BALANCE ITEM PAYMENT BALANCE $ $ $ $ $ $ $ per per per per per per per $ $ $ $ $ $ $ PLEASE CONTINUE BELOW IF NECESSARY 29. EXTRA SPACE Use this space if you ran out of room above. Please label your items as INCOME, ASSETS, PROPERTY, PAYMENTS, etc. $ $ $ $ $ $ $ per per per per per per per $ $ $ $ $ $ $

30. Attach a copy of last year's Federal Income Tax Return.

I declare that this financial statement has been examined by me and that its contents are true to the best of my information, knowledge, and belief. I further authorize the release of any information needed to verify this statement or any other information needed to verify my financial affairs. I understand that if I knowingly list any false information on this financial statement, I may be found in contempt of court.

Date Date

Signature Signature

Relationship to child(ren) Relationship to child(ren)

FOR COURT USE ONLY REVIEW AND RECOMMENDATIONS:

Signature