Free Financial Information Statement - District of Columbia

Form 7b. Financial Information Statement.

DISTRICT OF COLUMBIA COURT OF APPEALS Financial Information Statement (In Forma Pauperis)
Applicant's Name Case No. ____________________

1. MY MONTHLY INCOME (If your pay changes considerably from month to month, each of the amounts reported in item 1 should be your average for the past 12 months.) a. My gross monthly pay is:................................................................. b. My payroll deductions are (specify purpose and amount): (1) ___________________________________________________ (2) ___________________________________________________ (3) ___________________________________________________ (4) ___________________________________________________ My TOTAL payroll deduction amount is: ..................................................... $ __________ $ __________ $ __________ $ __________ $ __________ $ __________

c. My monthly take-home pay is (a. minus b.):......................................... $ __________ d. Other money I get each month is: (specify source and amount, include spousal support, child support, scholarships, retirement or pensions, social security, disability, unemployment, veterans payments, dividends, and net rental income) (1) ___________________________________________________ $ __________ (2) ___________________________________________________ $ __________ (3) ___________________________________________________ $ __________ The total amount of other money is: ................................................................ e. MY TOTAL MONTHLY INCOME IS (c. plus d.): ........................ $ __________ $ __________

2. PERSONS LIVING IN MY HOME. Number of persons living in my home: ________________________________________ Below list all persons living in your home, including your spouse, who depend in whole or in part on you for support or on whom you depend in whole or in part for support: Name 1. ________________________ 2. ________________________ 3. ________________________ 4. ________________________ 5. ________________________ Age _____ _____ _____ _____ _____ Relationship ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Gross Monthly Income $ __________ $ __________ $ __________ $ __________ $ __________ $ __________

The TOTAL amount of income from others living in my home is.............

2 3. PROPERTY. I own or have an interest in the following property: a. Cash: b. Bank accounts: c. Cars: d. Stocks e. Real estate (identify each property and note the fair market value and any loan balance): ________________________________________________________ ________________________________________________________ ________________________________________________________

$ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________

f. Other personal property (describe below): $ _________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 4. MY MONTHLY EXPENSES. My monthly expenses are the following: a. Rent/house payment & maintenance................................................ b. Food & household supplies.............................................................. c. Utilities and telephone...................................................................... d. Clothing............................................................................................ e. Laundry and cleaning....................................................................... f. Medical/dental payments.................................................................. g. Insurance (life, health, accident)...................................................... h. School and child care required for employment.............................. i. Court-ordered child or spousal support........................................... j Transportation and auto expenses (insurance, gas, repair)............... k. Installment payments (specify purpose and amount) (1) ____________________________________________________ $ __________ (2) ____________________________________________________ $ __________ (3) ____________________________________________________ $ __________ l. Amounts deducted due to wage assignments and earnings earnings withholding orders:........................................................... $ _________ _ _ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________

m. Other expenses (specify): (1) ____________________________________________________ $ __________ (2) ____________________________________________________ $ __________ (3) ____________________________________________________ $ __________ n. My Total monthly expenses are (add a. through m.) $ _________

5. Other facts that support this application are (describe unusual medical needs, expenses for recent family emergencies, or other unusual circumstances or expenses to help the court understand your budget; if more space is needed, attach a page labeled Attachment 5):