Free Financial Information Form for Family Courts.PDF - Texas

NOTICE:

This form is to be completed and a copy furnished to opposing counsel and to the Clerk of the Court prior to the hearing. All columns must be totaled. Provide past 2 years IRS returns and 2 most recent payroll stubs and if none, provide W-2 forms. FINANCIAL INFORMATION STATEMENT

NO. _________________________________________

_____________ District Court

____________________________________________ _____________________________________________ PETITIONER RESPONDENT ____________________________________________ _____________________________________________ ATTORNEY ATTORNEY 1. 2. 3. Date of Marriage: _________________________ Ages of Children: ( ) ( ) ( ) ( ) ( WIFE $ ________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ $ ________________________ Date of Separation: _____________________________ ) ( ) ( ) ( ) ( )

GROSS MONTHLY RESOURCES: Wages/Salary Overtime Bonus Commissions/Tips Interest on Savings Dividends Royalty Income Trust Income Net Rental Income Retirement/Pension Income Annuities Capital Gains Social Security Benefits Unemployment Benefits Disability/Workman's Comp. Interest on Notes Accounts Receivable Spousal Support/Alimony Other Income TOTAL RESOURCES:

HUSBAND _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ $ ________________________

4.

DEDUCTIONS: Withholding Tax FICA Retirement Union Dues Health Insurance Health Insurance for Children Miscellaneous TOTAL DEDUCTIONS: ($ _______________________ ) ( ________________________ ) ( ________________________ ) ( ________________________ ) ( ________________________ ) ( ________________________ ) ( ________________________ ) ($ _______________________ ) $ ($ ________________________) ( _________________________) ( _________________________) ( _________________________) ( _________________________) ( _________________________) ( _________________________) ($ ________________________) $

5. 6.

NET MONTHLY INCOME: EMPLOYMENT:

WIFE _______________________________________________________________________________________ HUSBAND ___________________________________________________________________________________ WIFE IS PAID EVERY: HUSBAND IS PAID EVERY: ¨ week ¨ week ¨ two weeks ¨ two weeks ¨ bimonthly ¨ bimonthly ¨ month ¨ month

Date Next Check is Received: WIFE____________________ HUSBAND_____________________ 7. QUICK ASSETS: Cash/Undeposited Checks Financial Institutions Stocks/Bonds Other WIFE $ ________________________ _________________________ _________________________ _________________________ HUSBAND $ ________________________ _________________________ _________________________ _________________________

I can borrow $________________________________ on my signature.

S:\FormsLib\Civil Bureau\Fam Juv & IVD Courts\Famcrt\Financial Information Form for Family Courts

Revised 5/29/96

8.

NECESSARY MONTHLY EXPENSES: House Payment/Rent Utilities Food Doctor/Dentist/etc. Insurance Payment Car Payments Gas/Oil/Parking Car Maintenance Child Care/School Tuition Lunches/Supplies Haircuts SUBTOTAL: $__________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ $__________________ SUBTOTAL FORWARD ___________________$ Clothing Cleaning/Laundry Legal Fees Gifts Church Support Entertainment/Activities for children Miscellaneous: ________________ ________________ ________________ TOTAL: ___________________ ___________________ ___________________ ___________________ ___________________ $ __________________ ___________________ ___________________ ___________________ ___________________ ___________________

9.

DEBTS (OTHER THAN LISTED IN NUMBER 8 ABOVE): AMOUNT ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ TOTAL MONTHLY: $__________________ ___________________ ___________________ ___________________ ___________________ ___________________ MONTHLY PAYMENT $_______________ ________________ ________________ ________________ ________________ ________________ $_______________ +$ _________________ $

10. 11.

GRAND TOTAL MONTHLY EXPENSES:

(ANSWER ONLY IF YOU ANTICIPATE RECEIVING SUPPORT) I feel that the following sums are reasonably necessary or within the ability of my spouse to pay, and it will be fair and equitable to require the following: EACH PAY PERIOD a. b. For temporary alimony For child support $_______________ + ______________ $_______________ + ______________ $_______________ $_______________ ( _______________ ) $_______________ MONTHLY $ __________________ + __________________ $ __________________ + __________________ $ __________________ $ __________________ ( __________________) $ __________________

12. 13. 14. 15. 16. 17. 18.

Total lines 11a and 11b Payee's Net Resources Total lines 12 and 13 Payor's Net Income Less Alimony and Support (line 12) Net Payor after deduction of child support and alimony

(ANSWER ONLY IF YOU ANTICIPATE PAYING SUPPORT) I feel that a reasonable sum for me to pay weekly or monthly would be: a. b. For temporary alimony For child support $_______________ + ______________ $_______________ $ __________________ + __________________ $ __________________

19.

Total lines 18a and 18b

DATE: ________________________

____________________________________________________ WIFE 'S SIGNATURE ____________________________________________________ HUSBAND'S SIGNATURE

DATE: ________________________

S:\FormsLib\Civil Bureau\Fam Juv & IVD Courts\Famcrt\Financial Information Form for Family Courts

Revised 5/29/96