Dr 6 Form PDF Details

In the pharmaceutical industry, there is a great deal of research and development that goes into the creation of each new drug. One important step in this process is formulating the drug so that it can be safely and effectively administered to patients. The 6th edition of the American Formulary (or Dr 6 Form) helps to ensure that drugs are properly formulated before they are released to the public. This guide provides information on dosage, strength, and composition of medications, as well as how they should be manufactured and packaged. It is an essential tool for pharmaceutical manufacturers, pharmacists, and other healthcare professionals.

QuestionAnswer
Form NameDr 6 Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesstatement assets family, dr6 form ri, rhode island dr 6, what is a dr6 form

Form Preview Example

STATE OF RHODE ISLAND

AND PROVIDENCE PLANTATIONS

 

 

STATEMENT OF ASSETS, LIABILITIES, INCOME AND EXPENSES

FAMILY COURT

DR-6/FINANCIAL STATEMENT

 

, S.C

Case #

 

A DR-6 shall be filed with Complaints for Divorce, Bed & Board Divorce, Miscellaneous Complaints or Child Support Complaints. A DR-6 shall be filed with Answers or Counterclaims; Modifications of Prior (Support) Orders.

 

vs.

 

 

 

Plaintiff

 

Defendant

Plaintiff's Attorney/Bar Number

Attorney's Phone Number

Defendant's Attorney/Bar Number

Attorney's Phone Number

1. PERSONAL INFORMATION

 

 

 

 

 

Name:

Telephone:

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

City/Town, State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

No. of Children Living With You:

 

 

 

 

 

 

Employer:

 

Occupation:

 

Employer's Address:

 

 

 

 

 

 

 

 

 

 

City/Town, State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

Employer's Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

2. DO YOU HAVE HEALTH INSURANCE?

If yes, single plan or family plan?

Name of Policy Holder:

Name of Insurance Provider:

Yes

No

Single

Family

Do you have a dental plan?

Yes

No

Name of Policy Holder:

 

 

 

Name of Insurance Provider:

 

 

 

 

 

 

Do you have a vision plan?

 

 

 

Yes

No

Name of Policy Holder:

 

 

 

Name of Insurance Provider:

 

 

 

 

 

 

DR-6

 

 

 

 

 

 

FC-5 (Revised October 2011)

 

1

3. TOTAL ASSETS (From Page 7)

$

-

TOTAL LIABILITIES (From Page 8)

 

$

-

Total Monthly Gross Income (From Page 2)

$

-

Total Monthly Expenses (From Page 5)

$

-

4. GROSS INCOME FROM ALL SOURCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

Bi-Weekly

 

Monthly

 

 

Annual

a) Base Pay from Salary/Wages

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

b) Overtime

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

c) Part-Time Job

 

 

 

 

 

 

$

-

d) Self-Employment (Attach a completed Schedule C

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

from your latest tax return)

 

 

 

 

 

 

$

-

e) Tips

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

f) Commissions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

g) Bonuses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

Subtotal:

 

 

 

 

 

 

 

 

 

$

-

$

-

$

-

$

-

h) Dividends

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

i) Interest

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

j) Trusts

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

k) Annuities

 

 

 

 

 

 

$

-

l) Pensions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

m) Retirement Funds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

n) Social Security

 

 

 

 

 

 

$

-

o) Disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

p) Unemployment Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

q) Worker's Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

r) Public Assistance (welfare, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

s) Child Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

t) Alimony

 

 

 

 

 

 

$

-

u) Rental from Income Producing Property (Attach a

 

 

 

 

 

 

$

-

completed Schedule A on Page 9)

 

 

 

 

 

 

v) Royalties and other rights

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

w) Contributions from household members

 

 

 

 

 

 

$

-

x) Income from S-Corps, C-Corps, LLCs, etc.

 

 

 

 

 

 

$

-

y) Capital Gains

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

z) Other Income (Specify below ):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

Total Gross Income:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

 

DR-6

 

FC-5 (Revised October 2011)

2

5. EXPENSES (pages 3, 4, and 5)

 

 

 

 

 

 

 

 

 

Weekly

 

 

Bi-Weekly

 

Monthly

 

Annual

1. Housing

 

 

 

 

 

 

 

 

Rent

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Mortgage Payment (Principle & Interest)

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Property Tax

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Condo Fee

 

 

 

 

 

 

$

-

Home Maintenance

 

 

 

 

 

 

$

-

Snow Removal/Lawn Care

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Total Housing:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

2. Utilities

 

 

 

 

 

 

 

 

Heating Oil

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Wood/Coal/Pellets

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Propane and Natural Gas

 

 

 

 

 

 

$

-

Telephone/Cell Phone

 

 

 

 

 

 

$

-

Electricity

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Cable Television/Internet

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Water and Sewer

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Trash Collection

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Total Utilities:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

3. Insurance

 

 

 

 

 

 

 

 

Homeowner

 

 

 

 

 

 

$

-

Renter

 

 

 

 

 

 

$

-

Vehicle

 

 

 

 

 

 

$

-

Health/Dental/Vision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Life

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Disability

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Total Insurance:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

4. Uninsured Health Care Expenses

 

 

 

 

 

 

 

 

Medical

 

 

 

 

 

 

$

-

Dental

 

 

 

 

 

 

$

-

Orthodontics

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Eye Care/Glasses/Contact Lenses

 

 

 

 

 

 

$

-

Prescription Drugs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Therapy and Counseling

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Total Uninsured Health Care Expenses:

$

-

$

-

$

-

$

-

 

Expenses Continued to page 4

DR-6

 

FC-5 (Revised October 2011)

3

5. EXPENSES (continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

 

Bi-Weekly

 

Monthly

 

Annual

 

 

 

 

 

 

 

 

 

 

5. Transportation

 

 

 

 

 

 

 

 

Primary Vehicle Payment

 

 

 

 

 

 

$

-

Other Vehicle Payments

 

 

 

 

 

 

$

-

Vehicle Maintenance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Gas and Oil

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Registration and Tax

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

Total Transportation:

$

-

$

-

$

-

$

-

6. General and Personal Expenses

 

 

 

 

 

 

 

 

Groceries

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Meals Eaten Out or Taken Out

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Tobacco/Alcohol Products

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Clothing and Shoes

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Hair Care

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Toiletries and Cosmetics

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Pet Food and Care

 

 

 

 

 

 

$

-

Church and Charities

 

 

 

 

 

 

$

-

Laundry and Dry Cleaning

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Gifts

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Newspapers and Magazines

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Education (personal)

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Dues and Memberships

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Vacations

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Entertainment and Recreation

 

 

 

 

 

 

$

-

Other:

 

 

 

 

 

 

$

-

Total General and Personal Expenses:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

 

7. Children's Expenses and Activities

 

 

 

 

 

 

 

 

Children's Clothing

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Diapers

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Day Care

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

School Supplies

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

School Lunches

 

 

 

 

 

 

$

-

Tuition and Lessons

 

 

 

 

 

 

$

-

Sports and Camps

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

Total Children's Expenses and Activities:

$

-

$

-

$

-

$

-

 

 

 

 

 

 

 

 

 

 

 

Expenses Continued to page 5

DR-6

 

FC-5 (Revised October 2011)

4

 

5. EXPENSES (continued)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weekly

 

Bi-Weekly

 

 

Monthly

 

Annual

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Other Expenses (For example, ungarnished child support or alimony). Specify below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Other Expenses:

$

-

$

-

 

$

-

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Deductions from Paycheck

 

 

 

 

 

 

 

 

 

 

 

Federal Income Tax

 

 

 

 

 

 

 

$

-

 

 

number of

 

 

 

 

 

 

 

 

 

 

 

exemptions:

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Income Tax

 

 

 

 

 

 

 

$

-

 

 

number of

 

 

 

 

 

 

 

 

 

 

 

exemptions:

 

 

 

 

 

 

 

 

$

-

 

 

Social Security

 

 

 

 

 

 

 

$

-

 

 

Medicare

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Local TDI

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State Retirement

 

 

 

 

 

 

 

$

-

 

 

Union Dues

 

 

 

 

 

 

 

$

-

 

 

Garnishments

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

401(k)

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Retirement Plans

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

$

-

 

 

Total Deductions from Paycheck:

$

-

$

-

 

$

-

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Financial

 

 

 

 

 

 

 

 

 

 

 

Loan Payments

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Debts

 

 

 

 

 

 

 

$

-

 

 

Savings

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRA

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Financial:

$

-

$

-

 

$

-

$

-

 

 

TOTAL EXPENSES:

$

-

$

-

 

$

-

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DR-6

 

 

 

 

 

 

 

 

 

 

FC-5 (Revised October 2011)

 

 

 

 

 

 

 

 

5

6. ASSETS

 

 

 

 

 

 

 

 

 

 

A. Real Estate

 

 

 

 

 

 

 

 

 

 

Primary Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: (street address,

city,

state,

zip)

 

 

 

 

 

 

Title Held in Name of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fair Market Value:

 

 

 

 

 

 

 

 

 

 

 

 

 

- Mortgage Balance:

 

 

 

 

 

 

 

 

 

 

 

 

 

Equity:

$

-

Real Estate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: (street address,

city,

state,

zip)

 

 

 

 

 

 

Title Held in Name of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fair Market Value:

 

 

 

 

- Mortgage Balance:

$

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equity:

$

-

Real Estate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address: (street address,

city,

state,

zip)

 

 

 

 

 

 

Title Held in Name of:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fair Market Value:

 

 

 

 

- Mortgage Balance:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equity:

$

-

 

 

 

 

 

 

 

Total Real Estate Equity:

 

 

 

 

 

 

 

 

 

$

-

B. Motor Vehicle:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

 

Make

 

Market Value

 

Vehicle Loan

 

Equity

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle 1

 

 

 

 

 

 

 

 

 

$

-

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total:

$

-

C. List IRA, Keough, Pension Profit Sharing, 401k, other Retirement or Financial Plans,

 

 

 

 

 

 

 

 

Financial Institution or Plan Names:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type

 

 

 

Name

 

 

 

Value

 

 

Total:

$

-

D. Annuity Plan(s):

Company Name

Value

 

Total:

$

-

 

 

 

 

E. Life Insurance: Present Cash Value

Company

Death Benefit

Cash Value

Total:

Assets Continued to page 7

DR-6

 

FC-5 (Revised October 2011)

6

6. ASSETS (continued)

F.) Savings and Checking Accounts, Money Market Accounts, Certificates of Deposit -- Which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Institutions

Type

Value

Total:

G.) List Mutual Funds, Stocks, Bonds, Savings Bonds, Brokerage Accounts:

Firm

Type

Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total:

H.) Financial Claims or Settlements from Any Source:

Description

Value

 

Total:

$

-

 

 

 

 

I.) Deferred Compensation:

Description

Value

Total:

J.) Additional Assets: (Ownership Interest in Corporation, LLC, Life Estate)

Type

Name

Value

 

Total:

$

-

 

 

 

 

 

TOTAL ASSETS:

$

-

 

 

 

 

DR-6

 

FC-5 (Revised October 2011)

7

7. LIABILITIES (For additional liabilities attach separate form)

Creditor

Nature of Debt

Date Incurred

Amount Due

Monthly Payment

TOTAL LIABILITIES:

$-

$-

Total Assets Minus Total Liabilities:

$-

I certify under the pains and penalties of perjury, the information stated on the DR-6, my financial statement and the attached schedules, if any, is complete, true and accurate.

Date

 

Signature

 

 

 

NOTARY CERTIFICATION

On this ________________ day of _____________________, 20____, before me personally appeared

___________________________________; he/she is personally known to me and/or he/she proved his/her identity

through satisfactory evidence of identification; he/she executed and acknowledged said instrument to be his/her free act and deed.

Notary Signature:

My Commission Expires:

FORM OF IDENTIFICATION:

 

 

 

Driver's License/State: __________

License Number

State of RI Identification

 

 

 

 

 

 

Passport

 

 

 

Birth Certificate

 

 

 

Other ID: _________________________

 

 

 

DR-6

 

 

 

FC-5 (Revised October 2011)

8

SCHEDULE A

RENT FROM INCOME PRODUCING PROPERTY

Gross Annual Rent Received:

Property Address:

Annual Rental Expenses:

Advertising:

Motor Vehicle and Travel:

Insurance:

Cleaning and Maintenance:

Commissions:

Interest on Mortgage to Banks:

Other Interest (Specify ):

:

:

Legal and Professional Services:

Repairs:

Supplies:

Taxes:

Utilities:

Wages:

Other Expenses:

:

:

Total Annual Rental Expenses:

$

-

 

Total Net Annual Rental Income:

 

$

-

Total Net Monthly Rental Income:

$

-

 

DR-6

 

 

 

 

 

 

 

 

 

FC-5 (Revised October 2011)

 

9

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1. Firstly, once filling out the rhode island dr 6, begin with the page that includes the following blanks:

The right way to fill out ri family court form dr 6 stage 1

2. Just after the prior selection of blanks is done, go to enter the applicable information in these - Employer, Employers Address, CityTown State, Employers Telephone Number, DO YOU HAVE HEALTH INSURANCE, If yes single plan or family plan, Name of Policy Holder, Name of Insurance Provider, Do you have a dental plan, Name of Policy Holder, Name of Insurance Provider, Do you have a vision plan, Name of Policy Holder, Name of Insurance Provider, and DR FC Revised October.

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3. Through this stage, have a look at TOTAL ASSETS From Page, TOTAL LIABILITIES From Page, Total Monthly Gross Income From, Total Monthly Expenses From Page, GROSS INCOME FROM ALL SOURCES, a Base Pay from SalaryWages, b Overtime, c PartTime Job d SelfEmployment, Weekly, BiWeekly, Monthly, Annual, Subtotal, e Tips, and f Commissions. These should be completed with highest attention to detail.

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4. To move ahead, this fourth step involves filling out a few blanks. Examples of these are m Retirement Funds, n Social Security, o Disability, p Unemployment Insurance, q Workers Compensation, r Public Assistance welfare etc, s Child Support, t Alimony u Rental from Income, v Royalties and other rights, w Contributions from household, x Income from SCorps CCorps LLCs, y Capital Gains, z Other Income Specify below, and Other, which you'll find fundamental to going forward with this form.

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