Section 26.39 Income and Expense Statement

• Library: Family Law Deskbook and 2014 Supp

4. (§26.39) Income and Expense Statement

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

[ ] At Kansas City [ ] At Independence

+-------------------------------------------------+
                |In re the Marriage of: |) | |
                |-----------------------------+--| |
                |___________________, |) | |
                |-----------------------------+--| |
                |Petitioner, |) |Cause No. ____ |
                |-----------------------------+--| |
                |and |) | |
                |-----------------------------+--| |
                |___________________, |) | |
                |-----------------------------+--| |
                |Respondent. |) | |
                +-------------------------------------------------+
                

INCOME AND EXPENSE STATEMENT OF

I. INCOME

A. GROSS WAGES PER PAY PERIOD $___________.

PAID : Weekly______ Bi-Weekly ______Semi-monthly______ Monthly ______________

B. My MONTHLY Gross Wages or Salary: $______

C. TAX STATUS: Single______ Married______ Head/household______

Number of Dependents Claimed ______

D. PAYROLL DEDUCTIONS EACH PAY PERIOD:

+----------------------------+---------------+
                | FICA (Social Security Tax) | $___________ |
                +----------------------------+---------------+
                | Medicare | $___________ |
                +----------------------------+---------------+
                | Federal Withholding Tax | $___________ |
                +----------------------------+---------------+
                | State Withholding Tax | $___________ |
                +----------------------------+---------------+
                | City Earnings Tax | $___________ |
                +----------------------------+---------------+
                | Union dues | $___________ |
                +----------------------------+---------------+
                | Health Insurance Premium | $___________ |
                +----------------------------+---------------+
                | Others: | $___________ |
                | ______________________ | |
                | ______________________ | |
                +----------------------------+---------------+
                

My total deductions each pay period $___________.

E. MY NET TAKE HOME PAY PER PAY PERIOD $___________

F. Additional Income: (List income from second jobs, rentals, dividends, social security, retirement. V.A., business enterprises. TANT. annuities, bonuses and all other sources.)

Source .............................................. Income

_________________________ $___________

_________________________ $___________

_________________________ $___________

My total average monthly additional gross income $_____________

G. The value of fringe benefits paid...