Free Microsoft Word - formcir_incomeexpense.doc - Tennessee

IN THE
vs.

C OURT OF DAVIDSON COUNTY, TENNESSEE
Complainant

CASE NO.

Defendant

INCOME AND EXPENSE STATEMENT
INCOME : It is mandatory to attach payroll records, leave earning statements from the military, or other proof of income for the past six most recent pay periods. A. 1. Employer: Address: 2. My gross wages and commission: Weekly Twice Monthly Monthly $ 3. Deductions each pay period: Federal Tax FICA Other $ 4. Net take-home earnings on a basis $ Other income (from any source): B. ................................................................... $ NET TAKE-HOME MONTHLY TOTAL Other Household Residents: C. 1. Name: Relationship to party: Net Income 2. Name: Relationship to party: Net Income D. Health Insurance: 1. Provided by employer : Cost to me: (yes/no) 2. Self-employed or provide own insurance: Cost to me: (yes/no) 3. No Health Insurance: 4. Coverage for Self Spouse # of Children Others

EXPENSES: Monthly Household Expenses: A. Rent/mortgage (including taxes and insurance) Water Electric Phone Car Operation Insurance Auto Payment Household Loans Other Monthly Payments B. General: Food Clothing Medical & Dental Laundry & Cleaning Recreation (specify) School Expenses Child Care Beauty/Barber Shop Other (specify) Other (specify) Other (specify) SUB-TOTALS Myself

Gas

$ $

Total Utilities

$ Children (# )

Total

$

$ TOTAL ALL EXPENSES

$ ......................................... $ ............................... $

Total General

C.

Anticipated Future Expenses (Attached) I need $ (Weekly/Monthly)

NET INCOME LESS EXPENSES

Last four digits of Social Security Number Sworn to and subscribed before me this day of
Signature of Notary Public

Plaintiff/Defendant , 20
Deputy Clerk

. My Commission Expires:

Print Form

Reset Form