§ Income and Expense Statement
Income and Expense Statement
Effective July 1, 2010.
[Publisher's note: Referenced interactive forms can be accessed at www.selfrepresent.mo.gov]
For use in Motions to Modify
In what Missouri county was the In the Circuit Court of
custody or support judgment entered? MISSOURI
What is the case number of the custody or support
judgment? Case Number Division Number
Answer all questions on this form completely.
Your Information My current full name is:
____________________ ________________ ________________ _________
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
[ ] I filed the original case. (Petitioner/Plaintiff)
[ ] I did not file the original case. (Respondent/Defendant)
[ ] I am the Mother
[ ] I am the Father
Other Party's The current full name of the other party is:
Information
____________________ ________________ ________________ _________
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
Monthly Income Mother Father
Information 1. Monthly Gross Income from Salaries, Wages and Commissions
including Bonuses ________ ________
2. Monthly Self-Employment Income ________ ________
3. Imputed Monthly Income ________ ________
4. Monthly Social Security Benefits not including Supplemental
Security Income (SSI) ________ ________
5. Monthly Retirement Benefits ________ _______
6. Monthly Pension Income ________ ________
7. Monthly Interest Income ________ ________
8. Monthly Trust and Annuity Income ________ ________
9. Monthly Income from Dividends and Partnership Distributions ________ ________
10. Monthly Unemployment Compensation Benefits ________ ________
11. Monthly Severance Pay ________ ________
12. Monthly Worker's Compensation Benefits ________ ________
13. Monthly Disability Insurance Benefits ________ ________
14. Monthly Veterans Disability Benefits ________ ________
Statement of Income and Expenses--Page 1 of 3
Form CAFC150-7/1/ This form is available for free at www.selfrepresent.mo.gov
2010
Monthly Income
Information
15. Monthly Military Allowances for Subsistence and Quarters ________ ________
16. Total Monthly Gross Income from Paragraphs 1 through 15(Also
enter on Form 14--Line 1)
________ ________
17. Monthly Supplemental Security Income Benefits (SSI) ________ ________
18. Monthly Payments of Temporary Assistance for Needy Families
(TANF)
________ ________
19. Monthly Medicaid Benefits ________ ________
20. Food Stamps ________ ________
21. Number of unemancipated children who are NOT the subject of
this proceeding that primarily reside with each parent (also enter
on Form 14--Line 2c(1))
_____ _____
Monthly amount of child support received pursuant to a court or
administrative order for unemancipated children who are NOT the
subject of this proceeding that primarily reside with each parent
(Also enter on Form 14--Line 2c(3))
________ _______
22. Monthly Maintenance Received in THIS case ________ ________
23. Monthly Maintenance Received in OTHER cases ________ ________
24. Total Monthly court ordered maintenance being received. Add
lines 22 and 23. (Form 14--Line 1a)
________ ________
Monthly Expense Mother Father
Information 25. Monthly court or administratively ordered child support being
paid for children who are NOT the subject of this Proceeding
________ ________
(Form 14--Line 2a)
26. Monthly Maintenance Paid in THIS case ________ ________
27. Monthly Maintenance Paid in OTHER cases ________ ________
28. Total Monthly Court Ordered Maintenance being Paid. Add lines
26 and 27. (Form 14--Line 2b)
________ ________
29. Reasonable work-related child care costs of the each parent for
the children who are the subject of this proceeding (Form
14--Line 6a and Line 6b)
_ _______ ________
30. Health insurance costs for the children who are the subject of this
proceeding (Form 14--Line 6c)
________ ________
31. Uninsured extraordinary medical costs for the children who are
the subject of this proceeding (Form 14--Line 6d)
________ ________
32. Other extraordinary child rearing costs for the children who are
the subject of this proceeding (Form 14- Line 6e)
________ ________
33. All Other Expenses of each Parent (Include housing costs,
utilities, transportation costs, food, clothing, loan payments,
charitable contributions, entertainment, insurance other than listed
in paragraph 8, etc.)
________ ________
Statement of Income and Expenses--Page 2 of 3
Form CAFC150-7/1/ This form is available for free at www.selfrepresent.mo.gov
2010
I certify under oath that I have given the other party a copy of this Income and Expense Statement pursuant to Missouri Supreme Court Rule 43.01(d) by: (You MUST check at least ONE of the following four boxes)
[ ] Mailing a copy to the other party or his or her attorney on __________(Date) at the following address:
_________________________________________________________________________
(Street)
________________________ _______________________ _______________________
(City) (State) (Zip)
[ ] Handing a copy to the other party or his or her attorney on __________ (Date).
[ ] Sending a copy to the other party or his or her attorney by fax to ____________________(fax number) on
_________________________(Date) at _______________(Time).
[ ] (To be used only by written consent of the party filed with the court) Sending a copy via electronic mail to the other party or his or her attorney at _____________________________________________(Email Address) on
____________________(Date).
Instructions: The following information MUST be filled in before a notary public. This Income and Expense Statement is
required to be verified before a notary public. The “Affiant” is the person that is completing this document.
COUNTY OF
_________________________________
)
) ss.
STATE OF _________________________________ )
Affiant, of lawful age, being duly sworn on his or her oath, states that he or she is the affiant named herein and that the facts stated in this Income and Expense Statement are true according to his or her best knowledge and belief.
_____________________________________________ ___________________________
Affiant--SIGN HERE (Sign here in front of a Notary Public) Affiant--PRINT YOUR NAME HERE
Subscribed and sworn to on
_________________________________________________.
_________________________________________________
Notary Public
My Commission Expires:
_________________________________________________
Statement of Income and Expenses--Page 3 of 3
Form CAFC150-7/1/ This form is available for free at www.selfrepresent.mo.gov
2010
[Publisher's note: Referenced interactive forms can be accessed at www.selfrepresent.mo.gov]