Free Income ­ Expense Affidavit - Louisiana

The Family Court of East Baton Rouge Parish, State of Louisiana

Income ­ Expense Affidavit
__________________________________
Petitioner

Suit Number __________________ Division ______________________ Judge ________________________

VS. __________________________________
Respondent

Income - Expense Affidavit of ________________________________________

A. Income:
Gross Monthly Income:
Source Amount

1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ Total Gross Monthly Income: Itemized Payroll Deductions
Source

$___________ $___________ $___________ $___________ $___________ $_____________
Amount

1. _______________________________________ 2. _______________________________________ 3. _______________________________________ 4. _______________________________________ 5. _______________________________________ 6. _______________________________________ 7. _______________________________________ 8. _______________________________________ 9. _______________________________________ 10. _______________________________________ Total Monthly Deduction Net Monthly Income:

$___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $_____________ $_____________

B. Living Expenses:
List all monthly living expenses excluding fixed debt. List present expenditures only; do not list future, anticipated, or speculative expenses. Spouse/Parent Child/Children

1. Rent/Mortgage Note 2. Food 3. Automobile Note 4. Clothing 5. Transportation (Fuel Cost) 6. Medical 7. Dental 8. Prescriptions 9. Household 10. Laundry 11. Personal Grooming 12. Utilities: (Electricity) (Gas) (Water) (Phone)
Form A, Income ­ Expense Affidavit Page 1 Form revised: September, 1999

$__________$___________ $__________ $___________ $__________ $___________ $__________ $__________ $__________ $___________ $__________ $___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________ $__________$___________

The Family Court of East Baton Rouge Parish, State of Louisiana

Income ­ Expense Affidavit
13. Educational Expenses:
Type For Whom

___________ ___________ ___________ ___________
Type

________________ ________________ ________________ ________________
For Whom

$___________ $___________ $___________ $___________

$___________ $___________ $___________ $___________

14. Other Expenses: ___________ ___________ ___________ ___________ ___________ ________________ ________________ ________________ ________________ ________________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________ $___________

Total Monthly Living Expenses

$______________$_____________

C. Fixed Debt
Other than mortgage and car debt listed above
Obligee Balance Due Date of Last Payment Monthly Payment

_________________ _________________ _________________ _________________ Total Fixed Debt

$__________ $__________ $__________ $__________

____________ ____________ ____________ ____________

$___________ $___________ $___________ $___________

$________________

$_________________

____________________________
Signed by (Litigant)

SWORN TO AND SUBSCRIBED, before me, Notary Public, on this _____day of _____________________________, year ________, at Baton Rouge, Louisiana.

____________________________
Signed by (Notary Public)

Form A, Income ­ Expense Affidavit Page 2 Form revised: September, 1999