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MADISON COUNTY SUPERIOR COURT. FINANCIAL DECLARATION Cause No. oc ms ted Ae | ee ee ‘Your GROSS monthly income i pad weekly, multiply by 43) Salary & Wages (including bonus & overtime pay) Ecoployes eee Ss Employer? B. Retirement or dsabilicy ee C._Chilevspouse suppor (prior marriage) so D. Unemployment compensation include SUB) Ss E, _Public assistance or welfare Ss FALL other sources (specify) —— s = __ oe Ss ee — se ‘TOTAL MONTHLY INCOME Ss Deductions from gross income: AL Taxes &FICA a B, Suppor order (prior mariage) ee © Insurance (medica se D. Union Duss so Boh Og ‘TOTAL DEDUCTIONS FROM GROSS a Disposable monthly income (minus 6) so List names, ages, and relationship of persons living in your household NAME AGE RELATIONSHIP ‘Are other persons in your household working? YesNo Iso, whe: ‘Occupation: 10. Monttly expenses for your household (pro rate annual expenses) A. Rent or Mortgage payment s B. Real Estate taxes (residence) Ss C. Real estate insurance (residence) = D. Food and household supplies s —_ E Clothing se F._ Utilities (electric, gas & water) se G.—_ Telephone s. H Insurance (life, auto) — 1 (Car payment s 2 Gasoline (auto) s__ K, Installment debs (minimum monthly payments) », se 2. s____ 2. a 4. so 9). Smertaa— ‘salient Toial—S. L. Other monthly expenses: (child care) Ss M. Other monthly expenses: s 11, Total monthly expenses: ASSETS (air Market Value) Real estate home Real estate-other Household goods Automobile: Make Model Ye ‘Automobile Make ‘Mode! Yr Savings assount ‘Checking account (Cash on hand Credit Union Retirement funds Life insurance-cash value Stocks and bonds TOTAL 12, NET WORTH: (line 7 minus 11) ‘LIABILITIES Ss Mortgage Si morgage 8 Debt on automobile S_____ Debt to Credit Union | certify under the penalties of pesury that the foregoing is rue and accurate Date ‘Sigaature