Wpf Drpscu Form – Fill Out and Use This PDF

Name:

Date of Birth:

I. Summary of Basic Information

Declarant’s Total Monthly Net Income (from § 3.3 below)

$

Declarant’s Total Monthly Household Expenses (from § 5.9 below)

$

Declarant’s Total Monthly Debt Expenses (from § 5.11 below)

$

Declarant’s Total Monthly Expenses (from § 5.12 below)

$

Estimate of the other party’s gross monthly income (from § 3.1f below)

[ ] $

[ ] unknown

a. If yes:

(1)

Where do you work. Employer's name and address must be listed on the

Confidential Information Form.

(2)

When did you start work there (month/year)?

_______________________

b. If no:

(1)

When did you last work (month/year)?

_______________________

(2)

What were your gross monthly earnings?

$

(3)

Why are you presently unemployed?

Name

Name

a.

Wages and Salaries

$

$

b.

Interest and Dividend Income

$

$

c.

Business Income

$

$

From ____________________________

$

$

e.

Other Income

$

$

f.

Total Gross Monthly Income (add lines 3.1a through 3.1e)

$

$

g.

Actual Gross Income (Year-to-date)

$

$

a.

Income Taxes

$

$

b.

FICA/Self-employment Taxes

$

$

c.

State Industrial Insurance Deductions

$

$

d.

Mandatory Union/Professional Dues

$

$

e.

Pension Plan Payments

$

$

f.

Spousal Maintenance Paid

$

$

g.

Normal Business Expenses

$

$

h.

Total Deductions from Gross Income

$

$

(add lines 3.2a through 3.2g)

3.3

Monthly Net Income (Line 3.1f minus line 3.2h or

$

$

line 3 from the Child Support Worksheet(s).)

a.

Child support received from other relationships

$

$

__________________________________________ $

$

__________________________________________ $

$

__________________________________________ $

$

__________________________________________ $

$

c.

Total Miscellaneous Income (add lines 3.4a through 3.4b)

$

$

3.5

Income of Other Adults in Household

$

$

IV. Available Assets

4.1

Cash on hand

$

4.2

On deposit in banks

$

4.3

Stocks and bonds, cash value of life insurance

$

4.4

Other liquid assets:

$

5.1

Housing

Rent, 1st mortgage or contract payments

$

Installment payments for other mortgages or encumbrances

$

Taxes & insurance (if not in monthly payment)

$

Total Housing

$

5.2

Utilities

Heat (gas & oil)

$

Electricity

$

Water, sewer, garbage

$

Telephone

$

Cable

$

Other

$

Total Utilities

$

5.3

Food and Supplies

Food for ___________ persons

$

Supplies (paper, tobacco, pets)

$

Meals eaten out

$

Other

$

Total Food Supplies

$

5.4

Children

Day Care/Babysitting

$

Clothing

$

Tuition (if any)

$

Other child-related expenses

$

Total Expenses Children

$

5.5

Transportation

Vehicle payments or leases

$

Vehicle insurance & license

$

Vehicle gas, oil, ordinary maintenance

$

Parking

$

Other transportation expenses

$

Total Transportation

$

5.6

Health Care (Omit if fully covered)

Insurance

$

Uninsured dental, orthodontic, medical, eye care expenses

$

Other uninsured health expenses

$

Total Health Care

$

Clothing

$

Hair care/personal care expenses

$

Clubs and recreation

$

Education

$

Books, newspapers, magazines, photos

$

Gifts

$

Other

$

Total Personal Expenses

$

Life insurance (if not deducted from income)

$

Other _____________________________________________

$

Other _____________________________________________

$

Total Miscellaneous Expenses

$

5.9

Total Household Expenses (The total of Paragraphs 5.1 through 5.8)

$

Description

Month of

Creditor

of Debt

Balance

Last Payment

Description

Month of

Amount of

Creditor

of Debt

Balance

Last Payment

Monthly

Payment

$

$

$

$

$

$

$

Total Monthly Payments for Other Debts and Monthly Expenses

$

5.12 Total Expenses (Add Paragraphs 5.9 and 5.11)

$

VI. Attorney Fees

6.1

Amount paid for attorney fees and costs to date:

$

6.3

Fees and costs incurred to date:

$

Signature of Declarant

Print or Type Name