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Circuit Court for Case No.City or County
Plaintiff Defendant
Address
City, State, Zip
Name
Address
FINANCIAL STATEMENT OF(General)
(CC-DR-031)
vs.
ITEM SELF CHILDREN TOTAL
A. PRIMARY RESIDENCEMortgageInsurance (homeowners)Rent/Ground RentTaxesGas & ElectricElectric OnlyHeat (oil)TelephoneTrash RemovalWater Bill
MONTHLY EXPENSES
Page 1 of 6CC-DR-031 (Rev. 09/2016)
(Name)
Name
City, State, Zip
(Md Rule 9-203 (a))
Telephone Telephone
Cell Phone/Pager
Repairs
Children Age
Lawn & Yard Care (snow removal)
Replacement Furnishings/Appliances
Condominium Fee (not included elsewhere)
Painting/Wallpapering
Carpet Cleaning
Domestic Assistance/Housekeeper
Pool
Other:
SUB TOTAL
B. SECONDARY RESIDENCE(i.e. Summer Home/Rental)
Mortgage
Insurance (homeowners)
Rent/Ground Rent
Gas & Electric
Electric Only
Heat (oil)
Telephone
Trash Removal
Water Bill
Cell Phone/Pager
Repairs
Lawn & Yard Care (snow removal)
Page 2 of 6CC-DR-031 (Rev. 09/2016)
C. OTHER HOUSEHOLD NECESSITIES
Replacement Furnishings/AppliancesCondominium Fee (not included elsewhere)
Painting/Wallpapering
Carpet Cleaning
Domestic Assistance/Housekeeper
Pool
Other:
SUB TOTAL
Food
Taxes
Drug Store ItemsHousehold SuppliesOther:SUB TOTAL
D. MEDICAL/DENTALHealth InsuranceTherapist/CounselorExtraordinary MedicalDental/OrthodontiaOphthalmologist/GlassesOther:SUB TOTAL
E. SCHOOL EXPENSESTuition/BooksSchool lunch
Page 3 of 6CC-DR-031 (Rev. 09/2016)
Extracurricular activities
Clothing/UniformsRoom & BoardDaycare/Nursery SchoolOther:SUB TOTAL
F. RECREATION & ENTERTAINMENTVacationsVideos/TheaterDining OutCable TV/InternetAllowanceCampMembershipsDance/Music Lessons etc.Horseback RidingOther:SUB TOTAL
G. TRANSPORTATION EXPENSEAutomobile PaymentAutomobile RepairsMaintenance/Tags/Tires/etc.Oil/GasAutomobile InsuranceParking FeesBus/Taxi
Page 4 of 6CC-DR-031 (Rev. 09/2016)
Other:SUB TOTAL
H. GIFTSHoliday Gifts
Birthdays
Gifts to Others
Charities
SUB TOTAL
I. CLOTHINGPurchasing
Laundry
Alterations/Dry Cleaning
Other:
SUB TOTAL
J. INCIDENTALSBooks & Magazines
Newspapers
Stamps/Stationery
Banking Expense
Other:
SUB TOTAL
K. MISCELLANEOUS/OTHERAlimony/Child Support (from a previous Order)
Religious Contributions
Page 5 of 6CC-DR-031 (Rev. 09/2016)
Hairdresser/Haircuts
Manicure/Pedicure
Pets/Boarding
Life Insurance
Other:
SUB TOTAL
TOTAL MONTHLY EXPENSES:Number of Dependent Children, including children who have not attained the age of 19 years, are notmarried or self-supporting, and are enrolled in secondary school:
GROSS MONTHLY WAGES:
Deductions:
Federal
State
Medicare
F.I.C.A.
Retirement
Total Deductions:
NET INCOME FROM WAGES:
OTHER GROSS INCOME:(alimony, part-time job, rentals etc.)
INCOME STATEMENT
Total deductions from Other income:
Deductions:a.
b.
NET OTHER INCOME
TOTAL MONTHLY INCOME
c.
Page 6 of 6CC-DR-031 (Rev. 09/2016)
Real EstateFurniture (in the marital house)Bank Accounts/SavingsU.S. BondsStocks/InvestmentsPersonal Property
AutomobilesBoatsOther:TOTAL ASSETS:
LIABILITIES:
MortgageAutomobilesNotes payable to relativesBank LoansAccrued TaxesBalance of Credit Card Accountsa.b.
ASSETS & LIABILITIES
Jewelry
ASSETS:
c.
Other:
TOTAL LIABILITIES
TOTAL NET WORTH:
SUMMARY:
TOTAL INCOME:
TOTAL EXPENSES:
EXCESS OR DEFICIT:
I solemnly affirm under the penalties of perjury that the contents of the foregoing Financial Statement,Monthly Expense List, and Assets and Liabilities Statement are true to the best of my knowledge,information, and belief.
Date Signature
