EXHIBIT A IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI
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1 EXHIBIT A IN THE CHANCERY COURT OF COUNTY STATE OF MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NUMBER DEFENDANT ************************************************************************ I. GENERAL INFORMATION: NAME: ADDRESS: CITY, STATE, ZIP CODE: DATE OF BIRTH: SOCIAL SECURITY NO.: OCCUPATION: EMPLOYER: EMPLOYER S ADDRESS: Exhibit A Page 1 of 8
2 NAME DATE OF BIRTH MINOR CHILDREN: EXHIBIT A (CONTINUED) II INCOME STATEMENT AMOUNT GROSS MONTHLY INCOME 1. Salary and Wages, including commissions Bonuses, allowance and overtime 1. NOTE: To arrive at a monthly income figure If paid weekly, multiply weekly income by 4.3, paid bi-weekly, multiply income by Pensions and retirement Social Security Disability and unemployment insurance Public assistance (welfare, AFDC payments, etc.) Dividends and interest Rental Income Other Income 8. Exhibit A Page 2 of 8
3 9. 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 Other (Specify) Other: (Specify) TOTAL MONTHLY DEDUCTIONS NUMBER OF EXPEMPTIONS: 11. NET MONTHLY PAY 11. EXHIBIT A (CONTINUED) III. EXPENSE STATEMENT A. LIVING EXPENSES AS OF 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. Exhibit A Page 3 of 8 7. Electricity
4 8. Gas (Residence) 9. Telephone 10. Laundry & Cleaning 11. Clothing 12. Insurance (Not payroll deducted) 13. Medical 14. Dental 15. Child Care 16. Children s allowance 17. Payment of Child Support / Alimony (Prior Marriage) 18. School Expense 19. Entertainment 20. Incidentals and Miscellaneous 21. Transportation other than Vehicle 22. Gas & 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 Expense 32. Maid 33. Retirement (IRA, etc.) 34. Pest Control B. TOTAL LIVING EXPENSES: 35. Installment Payment Notes, loans, charge accounts, etc OTHER EXPENSES: TOTAL INSTALLMENT PAYMENTS: $ COMBINED TOTAL EXPENSES: Exhibit A Page 4 of 8
5 IV STATEMENT OF ASSETS Exhibit B A. REAL ESTATE 1. Title in the name of: Address: Who paid cost: How cost paid: Value (Estimate) Mortgage Balance Equity $ $ 2. Title in the name of: Address: Who paid cost: How cost paid: Value (Estimate) Mortgage Balance Equity $ $ Note: List Mortgage Balance also under liabilities on the next page. List the amount of your monthly payment only under V. LIABILITIES. B. MOTOR VEHICLES 1. Registered in the name of : Year: Model: Mileage: How Cost Paid: How Cost Paid: VALUE: $ - Loan Balance $ = Equity $ Exhibit B Page 1 of 3 2. Registered in the name of:
6 Year: Model: Mileage: How Cost Paid: How Cost Paid: VALUE: $ - Loan Balance $ = Equity $ C. OTHER PERSONAL PROPERTY ( Such as home computers, guns, lawnmowers, TV s, jewelry, household furnishings, etc.) VALUE TOTAL D. CHECKING/ SAVINGS ( Name of Bank, Account Number and Amount in account, including CDs, money markets, passbook accounts, etc. ) Name on Account Bank Acct. No. Type of Account Balance TOTAL VALUE E. OTHER INVESTMENTS (IRAs, Stock(s), mutual funds, pension plans, etc. ) Bank / Account No. Type of Investment Balance F. LIFE INSURANCE (Exclude Children) Insured Company Face Amt. Cash Beneficiary (Less Loans) TOTAL CASH VALUE (LESS LOANS) Exhibit B Page 2 of 3 G. ALL OTHER ASSETS
7 TOTAL VALUE TOTAL OF ALL ASSETS STATEMENT OF LIABILITIES (Include mortgage, car loan, credit cards, personal loans) Note: Also include under items on Exhibit A A. Creditor Party Responsible Current Monthly Who Makes For Payment Balance Payment Payments B. TOTAL LIABILITIES ACKNOWLEDGMENT OF TRUTHFULNESS I declare to the court that the foregoing Exhibits A and B including statements, are true and correct and that this declaration was executed on the Day of 200. Exhibit B Page 3 of 3 EXHIBIT C IN THE CHANCERY COURT OF COUNTY
8 STATE OF MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NUMBER DEFENDANT CERTIFICATE OF COMPLIANCE I,, do hereby certify that I have thus complied with Rule 8.05 of the Uniform Chancery Court rules and that I have mailed and /or delivered a copy of a detailed written statement of actual income and expenses and assets and liabilities to the Attorney for the opposing party or the opposing party. SO CERTIFIED on this the Day of 200. Attorney for Opposing Party Exhibit C Page 1 of 1
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