Financial Statement Template 2008
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3Last updated on 10/3/2008
HURON COUNTY COMMON PLEAS COURT - JUVENILE DIVISION
FINANCIAL STATEMENT
1.
Make sure all question are answered in full even if you believe the Court already has the
information available.
2.
Attach a copy of your most recent income tax return, your most recent pay stub, and
verification of extraordinary medical expenses for the child, if any.
3.
RETURN THE COMPLETED WORKSHEET & YOUR MOST RECENT INCOME TAX RETURN TO
COURT. (Huron County Juvenile Court, 2 East Main Street, Room 101, Norwalk, Ohio 44857).
GENERAL INFORMATION
Date: ___________________________________________
Case Number: _________________________________________
My name is:_______________________________________________________________________________________________
My address is:____________________________________________________________________________________________
My telephone number is: (________)___________________ My Date of birth: ___________________________________
My spouse’s name is: __________________________________________ Spouse’s date of birth: ______________________
My child’s name is (for this case): _____________________________Child’s Date of Birth: ________________________
My relationship to the above named child is:_____________________________________________________________
MARITAL STATUS OF THE PARENTS OF THE ABOVE NAMED CHILD
Date and place of marriage: ________________________________________________
We were never married
Paternity was established (date / what court / case number): _______________________________________________
If divorced (date / what court / case number): _____________________________________________________________
MEDICAL INSURANCE INFORMATION
I HAVE medical insurance coverage for this child
I DO NOT HAVE medical insurance coverage for this child
I have a medical card from the Department of Job and Family Services for this child
I pay $_____________ for medical coverage for my family per
week /
bi-weekly /
monthly
I would pay $___________________ for medical coverage for myself per
week /
bi-weekly /
monthly
Insurance Company:______________________________________________Policy No._______________________________
Address:___________________________________________________________________________________________________
Note: You MUST attach verification from your employer of the amount you pay for medical coverage
for this child (family plan cost less the individual plan cost). If not attached you will not be given
credit for that expense.
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