Domestic & Family Blank Legal Forms
"APPLICATION FOR TEMPORARY
RELIEF"
This is not a substitute
for legal advice. An
attorney must be consulted.
"This
work is protected under the copyright laws of the United States. No
reproduction, use, or disclosure of this work shall be permitted without the prior express written authorization of the
copyright owner. Copyright © 2003 by LAWCHEK, LTD." |
BACK
TO BLANK LEGAL FORMS MENU
IN THE CIRCUIT COURT FOR
COUNTY,
(STATE)
|
CASE NO.: |
|
AFFIDAVIT OF INCOME
AND EXPENSES |
Petitioner, |
vs. |
|
|
|
Respondent. |
|
,
the Petitioner/Respondent hereinafter called Wife/Husband, being first duly sworn, upon
oath, respectfully represents to the Court that:
-
The parties were married on
; the Wife's age is
; the Husband's age is
.
-
The parties have been separated
months during which the Husband/Wife has paid $
to the Wife/Husband.
-
(a) There are
children of the parties, aged
, now in the care of the
Wife/Husband at
.
(b) The family home is owned/rented by the parties and is now occupied
by the Wife/Husband or both parties and
.
(c) For the best interest of the minor children, they should be in the
temporary custody of the Husband/Wife.
(d) The Wife has
minor children from a prior marriage. The amount of support received/paid is
$
per month.
(e) The Husband has
minor children from a prior marriage. The amount of support received/paid is
$
per month.
|
This
is not a substitute for legal advice. An
attorney must be consulted.
Copyright © 2003 - 2008 by
LAWCHEK, LTD. |
- The assets of the parties include:
APPROXIMATE MARKET VALUE AND ENCUMBRANCES
Item |
Wife |
Husband |
Jointly
Owned |
Encumbrances |
(a) Cars |
$ |
$ |
$ |
$ |
(Year/Make) |
|
|
|
|
(b) Stocks/Bonds |
$ |
$ |
$ |
$ |
(c) Cash/Savings |
$ |
$ |
$ |
$ |
(d) Claims |
$ |
$ |
$ |
$ |
(e) Acct. Receivable |
$ |
$ |
$ |
$ |
(f) Homestead |
$ |
$ |
$ |
$ |
- Secured Debts, not listed above (excluding homestead):
(a) Creditor |
1. |
2. |
3. |
4. |
(b) Total Outstanding |
$ |
$ |
$ |
$ |
(c) Monthly Payment |
$ |
$ |
$ |
$ |
(d) Party Obligated |
|
|
|
|
(e) Secured Pledged |
|
|
|
|
- Necessary monthly expenses: Wife/Husband
Child/Children, (if
separate)
(a) Rent |
$ |
$ |
(b) Mortgage Payment |
$ |
$ |
(c) Contract for Deed Payment |
$ |
$ |
(d) Homeowner's Insurance |
$ |
$ |
(e) Real Estate Taxes |
$ |
$ |
(f) Utilities |
$ |
$ |
(g) Heat |
$ |
$ |
(h) Food |
$ |
$ |
(i) Clothing |
$ |
$ |
(j) Laundry/Dry Cleaning |
$ |
$ |
(k) Medical/Dental |
$ |
$ |
(l) Transportation/Car Payment |
$ |
$ |
(m) Car Insurance |
$ |
$ |
(n) Life Insurance |
$ |
$ |
|
This
is not a substitute for legal advice. An
attorney must be consulted.
Copyright © 2003 - 2008 by
LAWCHEK, LTD. |
(o) Recreation/Entertainment/Travel |
$ |
$ |
(p) Newspapers/Magazines |
$ |
$ |
(q) Social/Church Obligations |
$ |
$ |
(r) Personal Allowances/Incidentals |
$ |
$ |
(s) Babysitting/Child Care |
$ |
$ |
(t) Home Maintenance |
$ |
$ |
(u) Children's Needs/Allowances |
$ |
$ |
(v) Additional Information regarding
debts and expenses: |
|
|
|
$ |
$ |
|
$ |
$ |
|
$ |
$ |
TOTAL: |
$ |
$ |
- EMPLOYMENT DATA: Provide the following data for each employer, and
attach prior month's paycheck stub(s) as Exhibit.
|
HUSBAND |
WIFE |
(a) |
Name of Employer |
|
|
|
Type of Employment |
|
|
(b) |
Income: |
|
|
1. Gross income per* |
$ |
$ |
2. Statutory Deductions: |
|
|
Federal Income Tax |
$ |
$ |
State Withholding |
$ |
$ |
Social Security (FICA) |
$ |
$ |
Pension Deductions |
$ |
$ |
Union Dues |
$ |
$ |
Dependent Health and
Hospitalization Coverage |
$ |
$ |
Dental Coverage |
$ |
$ |
3. Subtotal of Statutory Deductions |
$ |
$ |
4. Net Income (lines 1 - 3) |
$ |
$ |
5. Other Paycheck Deductions: |
|
|
Specify: |
$ |
$ |
|
$ |
$ |
6. Subtotal: (Other Deductions) |
$ |
$ |
7. NET TAKE-HOME PAY (lines 4-6) |
$ |
$ |
|
This
is not a substitute for legal advice. An
attorney must be consulted.
Copyright © 2003 - 2008 by
LAWCHEK, LTD. |
(c) |
Tax withholding figures above
are based on married or single taxpayers with # deductions
(Example:M-4 or S-2): |
$ |
$ |
(d) |
Employer Reimbursed Expenses:
Specify:
|
$
$ |
$
$ |
(e) |
Other Income: |
|
|
1. Public Assistance (AFDC/GA) |
$ |
$ |
2. Social Security Benefits for Party
or
Child/Children |
$ |
$ |
3. Unemployment/Workers’ Comp. |
$ |
$ |
4. Interest Income per |
$ |
$ |
5. Dividend Income per |
$ |
$ |
6. Gross Rental Income |
$ |
$ |
7. Other Income:
Specify:
|
$
$ |
$
$ |
* Monthly Income is to be calculated using a 4.3 multiple. |
-
(a)
$
is a reasonable amount for temporary support for
children per month.
(b) $
is a reasonable amount for temporary maintenance per month.
(c) Payment should be made on
.
-
$
has been paid on the Wife's attorney fees and costs.
$
has been paid on the Husband's attorney fees and costs.
$
is reasonable for Wife’s/Husband's attorney fees and
costs.
-
Additional Material Facts:
|
This
is not a substitute for legal advice. An
attorney must be consulted.
Copyright © 2003 - 2008 by
LAWCHEK, LTD. |
WHEREFORE, Petitioner/Respondent prays for an order granting such relief prior to
trial as may be just and lawful.
Subscribed and sworn to before me this
day of
,
.
|
|
|
(Notary Public) |
|
|
|
(County) (State) |
My commission expires on
. |
This
is not a substitute for legal advice. An
attorney must be consulted.
Copyright © 2003 - 2013 by LAWCHEK, LTD. |
This is not a substitute for legal
advice. An
attorney must be consulted.
Copyright © 2003 - 2013 by LAWCHEK, LTD.
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