IN THE CHANCERY COURT OF JACKSON COUNTY, MISSISSIPPI PLAINTIFF DEFENDANT RULE 8.05 FINANCIAL STATEMENT I.GENERAL INFORMTION NAME: ADDRESS:
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1 IN THE CHANCERY COURT OF JACKSON COUNTY, MISSISSIPPI VERSUS PLAINTIFF CAUSE NO: DEFENDANT RULE 8.05 FINANCIAL STATEMENT I.GENERAL INFORMTION NAME: ADDRESS: CITY, STATE AND ZIP CODE: DATE OF BIRTH: SOCIAL SECURTY NUMBER: OCCUPATION: EMPLOYER: EMPLOYERS ADDRESS: NAME M/F DATE OF BIRTH SOCIAL SEC. # MINOR CHILDREN: Page 1 of 9
2 II. INCOME STATEMENT GROSS MONTHLY INCOME 1. Salary and Wages, including commissions 1. bonuses, allowance and overtime NOTE: To arrive at a monthly income figure if paid weekly, multiply weekly income by 4.3, if paid bi-weekly, multiply income by Pensions and retirement Social Security Disability Public assistance (Welfare, AFDC payments, etc) Dividends and interest Rental income Other income Other income TOTAL MONTHLY INCOME 10. ITEMIZED MONTHLY DEDUCTIONS: 1. State Income Taxes Federal Income Taxes Social Security Mandatory Insurance Mandatory Retirement Union or other dues 6. Page 2 of 9
3 7. Other: (Specify) Other: TOTAL MONTHLY DEDUCTIONS 9. NUMBER OF EXEMPTIONS: 10. NET MOTHLY PAY 10. III. EXPENSE STATEMENT A. LIVING EXPENSES AS OF Self Children 1. Rent/Mortgage (Residence) 2. Real Property Taxes 3. Real Property Insurance 4. Maintenance (Residence) 5. Food/Household Supplies 6. Water, Sewer, etc. 7. Electricity 8. Gas (Residence) 9. Telephone 10. Laundry & Cleaning 11. Clothing 12. Insurance (Not Payroll Deducted) 13. Medical Page 3 of 9
4 14. Dental 15. Child Care 16. Children s Allowance 17. Payment of child support/ alimony (prior marriage) 18. School Expenses 19. Entertainment 20. Incidentals & Miscellaneous 21. Transportation other than vehicle 22. Gasoline & Oil (Auto) 23. Repair (Auto) 24. Insurance (Auto) 25. Auto Payments 26. Church Donations 27. Charitable Donations 28. Newspaper/Magazines 29. Cable TV 30. Pet Expenses 31. Yard Expenses 32. Maid Page 4 of 9
5 33. Retirement (IRA, etc.) 34. Pest Control TOTAL LIVING EXPENSES: 35. Installment Payments (Notes, loans, Charge accounts, etc.) OTHER EXPENSES: TOTAL INSTALLMENT PAYMENTS: COMBINED TOTAL EXPENSES Tax Returns provided for the following years: Forms W-2 provided for the following years: IV. STATEMENT OF ASSETS A. REAL ESTATE 1. Title in the name of: Address: Who paid cost: How cost paid: Value (estimate) Mortgage Balance Equity Page 5 of 9
6 2. Title in the name of: Address: Who paid cost: How cost paid: Value (estimate) Mortgage Balance Equity *List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under LIABILITIES. B. MOTOR VEHICLES 1. Registered in the name of: Year: Model: Mileage: Who paid cost: How cost paid: VALUE - Loan Balance = Equity 2. Registered in the name of: Year: Model: Mileage: Who paid cost: How cost paid: VALUE - Loan Balance = Equity 3. Registered in the name of: Year: Model: Mileage: Who paid cost: How cost paid: VALUE - Loan Balance = Equity Page 6 of 9
7 TOTAL VEHICLE EQUITY C. OTHER PERSONAL PROPERTY (such as home computers, guns, lawnmowers, televisions, jewelry, household furnishings, etc.) Values D. CHECKING/ SAVINGS (name of Bank, Account Number and Amount in Account, including CD s, money markets, passbook accounts, etc.) Name(s) on Account Bank/Acct. No. Type Acct. Balance E. OTHER INVESTMENTS (IRA s stock(s), mutual funds, pension plans, etc.) Bank/Acct. No. Type of Investment Balance F. LIFE INSURANCE (exclude children) Insured Company Face Amt Cash Beneficiary Less any Loans TOTAL CASH VALUE (LESS LOANS) $ Page 7 of 9
8 G. ALL OTHER ASSETS VALUES TOTAL OF ALL ASSETS V. STATEMENT OF LIABILITIES TOTAL VALUE $ $ LIABILITIES (Include mortgage, car loan, credit cards, personal loans). (Include also under of III B) Creditor Whose Name(s) Current Monthly Who Pays Bal. Due payment P or D TOTAL LIABILITIES $ Page 8 of 9
9 VI. GENERAL STATEMENT DESCRIBING EMPLOYMENT HISTORY Date of Marriage/Divorce Dates Employer/Address Earnings ACKNOWLEDGMENT OF TRUTHFULNESS I DECLARE TO THE Court that the foregoing Rule 8.05 Financial Statement including attachments, is true and correct and that this declaration was executed on the day of, 20. Party s Signature Page 9 of 9
EXHIBIT A IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI
EXHIBIT A IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NUMBER DEFENDANT ************************************************************************ I. GENERAL INFORMATION:
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