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CIRCUIT COURT

DISTRICT COURT OF MARYLAND FOR...............................................
City/County Court Address

Located at ...................................................................................Case No.................................................. ......................................................................................
Petitioner

vs. ......................................................................................
Respondent

FINANCIAL STATEMENT
Person for whom support is needed: Name ................................................................ ................................................................ ................................................................ MONTHLY INCOME: My pay before taxes ........................ $ ......................... My pay after taxes ........................... $ ......................... Other deductions from my pay (explain) ......................................................... $ ......................... ......................................................... $ ......................... Final amount of my paycheck ......... $ ......................... (I am paid every week 2 weeks month other.) Name of my employer:................................................. Address of my employer: ............................................. ...................................................................................... I have other income as follows (list second job, AFDC, unemployment, court-ordered support, etc. List how much you receive, how often, and who pays it.) ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ...................................................................................... ASSETS I own the following items of value, either by myself or with someone else: (List cash, cars, bank accounts, houses, and any other property either owned separately or jointly with another. State how much each is worth.) ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ..................................................................................... . Date Birth Date or Age ............................ ............................ ............................ Address ............................................................................... ............................................................................... ............................................................................... MONTHLY EXPENSES: (see below*) Rent/Mortgage................................. $ ......................... Food................................................. $ ......................... Transportation.................................. $ ......................... Light/Gas/Heat ................................ $......................... Telephone ........................................ $ ......................... Child Care (during work hours) ...... $ ......................... Health Ins. (if children covered)...... $ ......................... Court-Ordered Child Support or Alimony.................................. $........... .............. Other (explain)................................. $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... DEBTS I owe the following amounts to the following creditors: (List the person/company you owe and how much is owed.) ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................... $ ......................... ......................................................................................
Signature

*Expenses should include expenses for children if they are residing with you. To figure the monthly amount, weekly expenses should be multiplied by 4.3 and yearly expenses should be divided by 12. If you do not pay the same amount each month for any of the categories listed, figure what your average monthly expense is.

CC-DC/DV 4 (Rev. 7/2003)

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