Official form section
Court case information Judicial circuit
County
Case number
Division
Petitioner
Respondent
Official form section
Employment information Full legal name
Occupation
Employed by
Business address
Pay rate
Pay frequency Select one Every week Every other week Twice a month Monthly Other
Other pay frequency
Check here if unemployed Select one Check this box
Official form section
Present monthly gross income 1. Monthly gross salary or wages
2. Monthly bonuses, commissions, allowances, overtime, tips, and similar payments
3. Monthly business income
4. Monthly disability benefits/SSI
5. Monthly Workers' Compensation
6. Monthly Unemployment Compensation
7. Monthly pension, retirement, or annuity payments
8. Monthly Social Security benefits
9a. Monthly alimony actually received from this case
9b. Monthly alimony actually received from other cases
10. Monthly interest and dividends
11. Monthly rental income
12. Monthly income from royalties, trusts, or estates
13. Monthly reimbursed expenses and in-kind payments
14. Monthly gains derived from dealing in property
15-16. Other income of a recurring nature
15-16. Identify the source of other recurring income
Official form section
Present monthly deductions 18. Monthly federal, state, and local income tax
19. Monthly FICA or self-employment taxes
20. Monthly Medicare payments
21. Monthly mandatory union dues
22. Monthly mandatory retirement payments
23. Monthly health insurance payments
24. Monthly court-ordered child support actually paid for children from another relationship
18a. Filing status
18b. Number of dependents claimed
25a. Monthly court-ordered alimony actually paid from this case
25b. Monthly court-ordered alimony actually paid from other cases
Official form section
Average monthly expenses Mortgage or rent
Property taxes
Utilities
Telephone
Food
Meals outside home
Maintenance/Repairs
Household - Other description
Household - Other amount
Gasoline
Repairs
Insurance
Day care
Lunch money
Clothing
Grooming
Gifts for holidays
Medical/Dental (uninsured)
Children's expenses - Other description
Children's expenses - Other amount
Medical/Dental insurance
Children's medical/dental insurance
Life insurance
Insurance - Other description
Insurance - Other amount
Clothing
Medical/Dental (uninsured)
Grooming
Entertainment
Gifts
Religious organizations
Miscellaneous
Other expense 1 - description
Other expense 1 - amount
Other expense 2 - description
Other expense 2 - amount
Other expense 3 - description
Other expense 3 - amount
Other expense 4 - description
Other expense 4 - amount
Other expense 5 - description
Other expense 5 - amount
Other expense 6 - description
Other expense 6 - amount
Creditor 1
Creditor 1 - monthly payment
Creditor 2
Creditor 2 - monthly payment
Creditor 3
Creditor 3 - monthly payment
Creditor 4
Creditor 4 - monthly payment
Creditor 5
Creditor 5 - monthly payment
Creditor 6
Creditor 6 - monthly payment
Creditor 7
Creditor 7 - monthly payment
Creditor 8
Creditor 8 - monthly payment
Creditor 9
Creditor 9 - monthly payment
Creditor 10
Creditor 10 - monthly payment
Creditor 11
Creditor 11 - monthly payment
Official form section
Assets Cash on hand - current fair market value
Cash on hand - check if requesting the judge award this item to you Select one Check this box
Cash on hand - nonmarital owner Select one Petitioner Respondent
Cash in banks or credit unions - current fair market value
Cash in banks or credit unions - check if requesting the judge award this item to you Select one Check this box
Cash in banks or credit unions - nonmarital owner Select one Petitioner Respondent
Stocks, Bonds, Notes - current fair market value
Stocks, Bonds, Notes - check if requesting the judge award this item to you Select one Check this box
Stocks, Bonds, Notes - nonmarital owner Select one Petitioner Respondent
Real estate: Home - current fair market value
Real estate: Home - check if requesting the judge award this item to you Select one Check this box
Real estate: Home - nonmarital owner Select one Petitioner Respondent
Real estate: Other - current fair market value
Real estate: Other - check if requesting the judge award this item to you Select one Check this box
Real estate: Other - nonmarital owner Select one Petitioner Respondent
Automobiles - current fair market value
Automobiles - check if requesting the judge award this item to you Select one Check this box
Automobiles - nonmarital owner Select one Petitioner Respondent
Other personal property - current fair market value
Other personal property - check if requesting the judge award this item to you Select one Check this box
Other personal property - nonmarital owner Select one Petitioner Respondent
Retirement plans - current fair market value
Retirement plans - check if requesting the judge award this item to you Select one Check this box
Retirement plans - nonmarital owner Select one Petitioner Respondent
Other asset 1 - description
Other asset 1 - current fair market value
Other asset 1 - check if requesting the judge award this item to you Select one Check this box
Other asset 1 - nonmarital owner Select one Petitioner Respondent
Other asset 2 - description
Other asset 2 - current fair market value
Other asset 2 - check if requesting the judge award this item to you Select one Check this box
Other asset 2 - nonmarital owner Select one Petitioner Respondent
Other asset 3 - description
Other asset 3 - current fair market value
Other asset 3 - check if requesting the judge award this item to you Select one Check this box
Other asset 3 - nonmarital owner Select one Petitioner Respondent
Other asset 4 - description
Other asset 4 - current fair market value
Other asset 4 - check if requesting the judge award this item to you Select one Check this box
Other asset 4 - nonmarital owner Select one Petitioner Respondent
Other asset 5 - description
Other asset 5 - current fair market value
Other asset 5 - check if requesting the judge award this item to you Select one Check this box
Other asset 5 - nonmarital owner Select one Petitioner Respondent
Other asset 6 - description
Other asset 6 - current fair market value
Other asset 6 - check if requesting the judge award this item to you Select one Check this box
Other asset 6 - nonmarital owner Select one Petitioner Respondent
Assets - check here if additional pages are attached Select one Check this box
Total assets - nonmarital owner column Select one Petitioner Respondent
Official form section
Liabilities First mortgage on home - current amount owed
First mortgage on home - check if requesting responsibility for this debt Select one Check this box
First mortgage on home - nonmarital owner Select one Petitioner Respondent
Second mortgage on home - current amount owed
Second mortgage on home - check if requesting responsibility for this debt Select one Check this box
Second mortgage on home - nonmarital owner Select one Petitioner Respondent
Other mortgages - current amount owed
Other mortgages - check if requesting responsibility for this debt Select one Check this box
Other mortgages - nonmarital owner Select one Petitioner Respondent
Other mortgage row - description
Other mortgage row - current amount owed
Other mortgage row - check if requesting responsibility for this debt Select one Check this box
Other mortgage row - nonmarital owner Select one Petitioner Respondent
Auto loans - description
Auto loans - current amount owed
Auto loans - check if requesting responsibility for this debt Select one Check this box
Auto loans - nonmarital owner Select one Petitioner Respondent
Charge/credit card account 1 - description
Charge/credit card account 1 - current amount owed
Charge/credit card account 1 - check if requesting responsibility for this debt Select one Check this box
Charge/credit card account 1 - nonmarital owner Select one Petitioner Respondent
Charge/credit card account 2 - description
Charge/credit card account 2 - current amount owed
Charge/credit card account 2 - check if requesting responsibility for this debt Select one Check this box
Charge/credit card account 2 - nonmarital owner Select one Petitioner Respondent
Charge/credit card account 3 - description
Charge/credit card account 3 - current amount owed
Charge/credit card account 3 - check if requesting responsibility for this debt Select one Check this box
Charge/credit card account 3 - nonmarital owner Select one Petitioner Respondent
Other debt 1 - description
Other debt 1 - current amount owed
Other debt 1 - check if requesting responsibility for this debt Select one Check this box
Other debt 1 - nonmarital owner Select one Petitioner Respondent
Other debt 2 - description
Other debt 2 - current amount owed
Other debt 2 - check if requesting responsibility for this debt Select one Check this box
Other debt 2 - nonmarital owner Select one Petitioner Respondent
Other debt 3 - description
Other debt 3 - current amount owed
Other debt 3 - check if requesting responsibility for this debt Select one Check this box
Other debt 3 - nonmarital owner Select one Petitioner Respondent
Liabilities - check here if additional pages are attached Select one Mark this line
Total debts - nonmarital owner column Select one Petitioner Respondent
Official form section
Contingent assets and liabilities Contingent asset 1 - description
Contingent asset 1 - possible value
Contingent asset 1 - check if requesting award to you Select one Check this box
Contingent asset 1 - nonmarital owner Select one Petitioner Respondent
Contingent liability 1 - description
Contingent liability 1 - possible amount owed
Contingent liability 1 - check if requesting responsibility Select one Check this box
Contingent liability 1 - nonmarital owner Select one Petitioner Respondent
Contingent asset 2 - description
Contingent asset 2 - possible value
Contingent asset 2 - check if requesting award to you Select one Check this box
Contingent asset 2 - nonmarital owner Select one Petitioner Respondent
Contingent liability 2 - description
Contingent liability 2 - possible amount owed
Contingent liability 2 - check if requesting responsibility Select one Check this box
Contingent liability 2 - nonmarital owner Select one Petitioner Respondent
Total contingent assets - nonmarital owner column Select one Petitioner Respondent
Total contingent liabilities - nonmarital owner column Select one Petitioner Respondent
Official form section
Child support guidelines worksheet Child Support Guidelines Worksheet Select one A Child Support Guidelines Worksheet is or will be filed in this case A Child Support Guidelines Worksheet is not being filed in this case
Official form section
Your contact information for the signature page Printed name of party
Party address
Party city, state, and ZIP code
Party telephone number
Party fax number
Party e-mail address
