Financial Statement Template 2008 Page 3
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1
2
3CHILD SUPPORT & SPOUSAL SUPPORT ORDERS:
TOTAL NUMBER: __________________
LIST ALL YOUR CHILDREN UNDER THE AGE OF 18
Name
DOB
Do they live with you?
Child care expenses if any?
Example: Susie Smith
1/15/81
No
No
John Doe
1/31/89
Yes
$40.00 per week
__________________________
____________________________ ___________________________ ___________________
__________________________
____________________________ ___________________________ ___________________
__________________________
____________________________ ___________________________ ___________________
Note: You must provide the name of your daycare provider and proof of how much you pay. If not
attached you WILL NOT be given credit for that expense.
I pay child support for the following children:
Name
Date of birth
Amount paid
Case No. & Court
Example: Susie Smith 1/15/81
$51.00 per week
95-1111 / Huron Co. Juvenile Court
________________________
__________________
___________________
_________________________
________________________
__________________
___________________
_________________________
________________________
__________________
___________________
_________________________
Note: You MUST provide the name of your daycare provider and proof of how much you pay. If not
attached you WILL NOT be given credit for that expense.
I receive child support for the following children:
Name
Date of birth
Amount paid
Case No. & Court
Example: John Doe
1/31/89
$51.00 per week
95-1111 / Huron Co. Juvenile Court
________________________
__________________
___________________
_________________________
________________________
__________________
___________________
_________________________
________________________
__________________
___________________
_________________________
I pay spousal support in the amount of $_________________ per week
Case No. _____________ Court: _______________
I receive spousal support in the amount of $________________ per week Case No. _____________ Court: _______________
EXTRAORDINARY EXPENSES
List any extraordinary expenses (such as medical, school tuition, etc.) you have that you feel the Court should be aware of when
determining your child support obligation. (Do not include normal expenses such as rent/mortgage, utilities, car payments, etc.)
Note: You must attach verification of payment for extraordinary expenses. Attach copies of the child’s medical bills including
date of service, what service was provided, what amount insurance paid, what amount was paid out-of-pocket, and what amount
remains due.
Attach documentation from the child’s school regarding the amount paid for tuition.
If verification is not
attached you will not be given credit for that expense.
I hereby acknowledge that the information contained in this financial statement is true and accurate to the best of my ability.
________________________________________________
Signature
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