Section 26.39 Income and Expense Statement

• Library: Family Law 2014 Supp Forms

The form below is the Income and Expense Statement used by the Sixteenth Circuit Court and is available as a PDF or Word document on the internet at:

www.16thcircuit.org/Forms/CVL/FamilyCourtDomestic/1402b.pdf

IN THE CIRCUIT COURT OF JACKSON COUNTY. MISSOURI FAMILY COURT DIVISION Z At Kansas City Z At Independence

IN RE THE MARRIAGE OF:

_____ Case No.____

Petitioner.

and

Respondent

INCOME AND EXPENSE STATEMENT OF_

I. INCOME

A. GROSS WAGES PER PAY PERIOD S_

PAID : Weekly_Bi-Weekly_Semi-monthly_Monthly_

B. My MONTHLY Gross Wases or Salary: S_

C. TAX STATUS Single__Married__Head/household_

Number of Dependents Claimed _

D. PAYROLL DEDUCTIONS EACH PAY PERIOD:

FICA (Social Security Tax) S__

Medicare S___

Federal Withholding Tax S_____

State Withholding Tax S___

City Earnings Tax S___

Union dues S___

Health Insurance Premium S___

Others: S

My total deductions each pay period $____

MY NET TAKE HOME PAY PER PAY PERIOD S.

Additional Income: (List income from second jobs, rentals, dividends, social security, retirement. V.A., business enterprises. TANF...