Free mc287.pmd - Michigan

Approved, SCAO

STATE OF MICHIGAN
Court address

FINANCIAL STATEMENT

CASE NO.
Court telephone no.

PERSONAL INFORMATION
Name (last, first, middle) Address Home phone no. house Work phone no. apartment lot no. City Driver's license no. Marital status Relationship Dates of birth Student (Yes/No) Single Divorced State Married Date of birth Zip E-mail address Separated Widowed If divorced, date final Phone no. SSN (last 4 digits)

Cellular phone no.

Mailing address (if different than above) Name and address of nearest living relative Names of dependents

College/University

Employer 1 (Company name and address) Employer 2 (Company name and address) If self-employed, type of business/trade Have you ever filed for bankruptcy? Vehicle #1 Vehicle #2 Bank/Financial account no. Investment/Brokerage account no. Yes No If unemployed, source of support If yes, date filed

Length of employment Length of employment General assistance Food stamps Date completed Present value $ Present value $ Present balance $ Present balance $ Value $ $ SSI AFDC

ASSETS
Year / Make Year / Make Name and address of financial institution Name and address of financial institution

Other property such as real estate, boats, snowmobiles (describe) TOTAL ASSETS

MONTHLY INCOME
Gross monthly income (self) Gross monthly income (spouse) Unemployment benefits Social security Retirement/Pension benefits Child support Alimony/Maintenance Disability Veteran's benefits Interest/Dividends Other (cash): TOTAL INCOME $ $ $ $ $ $ $ $ $ $ $ $

MONTHLY EXPENSES
Mortgage or rent Utilities Vehicle payments Insurance (vehicle/health/life) Other loan payments Child support/Alimony Medical payments Court payments Other: $ $ $ $ $ $ $ $ $

TOTAL EXPENSES

$

Financial Report Authorization: I authorize the court, the court's funding unit, and their employees or agents to obtain a consumer credit report and other financial information about me from a consumer credit reporting agency or any other entity. I certify under penalty of perjury that this financial statement is a complete and accurate statement of my income, assets, and expenses, and that I have no other additional income. I will provide supporting documentation of income and debts upon request.
Date MC 287 (3/09) Signature

FINANCIAL STATEMENT