cjd301

ASSETS

Extra Information:

Weekly Expenses Continued

Life Insurance

Medical Insurance

Uninsured Meidcals

Incidentals and Toiletries

Motor Vehicle Expenses

Motor Vehicle Payment

Child Care

Extra Information:

Life insurance: Present Cash Value?

Extra Information:

Tax deferred Annuity Plans?

Extra Information:

Tell us about your car.

Fair Market Value

Car Loan Left

Extra Information:

Do you earn a salary or are you paid wages?

Extra Information:

Income

How much do you earn in base pay?

How often do you get paid?*

Extra Information:

Do you have health insurance?

Extra Information:

What is your health insurance?

Extra Information:

Income Information

We need to ask you about your income now.

Extra Information:

Do you have any other expenses?

Other expenses*

How much is this expense?

Other expenses (continued)

How much is this expense?

Extra Information:

Part VIII

Weekly Expenses

Extra Information:

Weekly Expenses

Rent or Mortgage

Homeowners/Tenant Insurance

Maintenance and Repair

Heat

Electricity and/or Gas

Telephone

Water/Sewer

Food

House Supplies

Laundry and Cleaning

Clothing

Extra Information:

Other Deductions From Salary/Wages

Credit Union Loans

Credit Union Savings

Savings

Retirement

Other deductions?

Amount of other deducted

Extra Information:

How many years have you paid into social security?

Years paid into social security?

Extra Information:

Do you have other sources of income?

Extra Information:

Additional Income. If not applicable leave blank.

Tips

Commissions

Bonuses

Dividends

Income from Interest

Trusts

Annuities

Pensions

Retirement Funds

Extra Information:

Part III

Itemized Deductions from Gross Income

Extra Information:

Do you receive income from overtime or part time work?

Overtime pay?

Part Time Work

Extra Information:

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Financial Institution or Plan Name

Account #

Current Account Balance

Extra Information:

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Financial Institution or Plan Name

Account #

Current Account Balance

Extra Information:

Please list off your liabilities.

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

Extra Information:

Please answer the following information about your income tax deductions

How many federal exemptions do you claim?

How many state income tax deduction exemptions do you have?

Extra Information:

Please list off your liabilities.

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

Extra Information:

Please list off your liabilities.

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

Extra Information:

Do you have any debts?

Extra Information:

STOCKS

Stock Name

Stock Value

Extra Information:

STOCKS

Stock Name

Stock Value

Extra Information:

Income Tax Deductions

How much is deducted for federal income tax?

How much is deducted for state income tax?

How much is deducted for fica and medicare?

How much is deducted for medical insurance

How much is deducted for union dues?

Extra Information:

Please list off your liabilities.

Creditor

Nature of Debt

Date Incurred

Amount Due

Weekly Payment

Extra Information:

Do you have any of the following:

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans?

Extra Information:

Do you have a job?

Extra Information:

Employment Information

Occupation

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Telephone

Extra Information:

Do you have children living with you?

Extra Information:

How many children do you live with?

Extra Information:

What is your home address?

Address

City

State

Zip Code

Extra Information:

Info

Telephone Number

Date of Birth

Extra Information:

Disclaimer

This is not legal advice.

Extra Information:

Case Info

Where is your case?*

Are you the plaintiff or defendant?*

Plaintiff Name

Defendant Name

Extra Information:

Part III
Itemized Deductions from Gross Income

Extra Information:

What are they?

Other Incomes

How much from this income stream?

Other Incomes

How much from this income stream?

Extra Information:

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Financial Institution or Plan Name

Account #

Current Account Balance

Extra Information:

Do you receive child support or alimony?

Extra Information:

Do you receive any of the following?

Social Security

Disability

Unemployment Insurance

Workers Comp?

Public Assistance?

Extra Information:

Any rental income or royalties?

Extra Information:

CHILD SUPPORT ALIMONY

Child Support

Alimony

Extra Information:

Any contributions from household members... explained in detail?

Extra Information:

rental and royalties

Rental Income

Royalties

Extra Information:

Are there any other source of income not mentioned here?

Extra Information:

CALCULATE Contributions card

Contributions from Other Family Members

Extra Information:

Stocks, Bonds, Collections or others?

Extra Information:

Savings and Checking Accounts?

Extra Information:

DOWNLOAD THE DOCUMENT AND SEND IT IN

Extra Information:

Do you own any real estate?

Extra Information:

LIBABILITES

Extra Information:

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Extra Information:

Tax Deferred Annuity Plan(s)

Extra Information:

Life Insurance: Present Cash Value

Extra Information:

Tell us about your car.

Fair Market Value

Car Loan Left

Extra Information:

Do you own a motor vehicle?

Extra Information:

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Extra Information:

Answer the following about any real estate you might own.

Location

Title held in the name of

Fair Market Value

Mortgage Remaining

Extra Information:

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Extra Information:

CDJ 301 Financial Form

A LSC Project

This page is currently unavailable

ASSETS

Weekly Expenses Continued

Life insurance: Present Cash Value?

Tax deferred Annuity Plans?

Tell us about your car.

Do you earn a salary or are you paid wages?

Income

Do you have health insurance?

What is your health insurance?

Income Information We need to ask you about your income now.

Do you have any other expenses?

Part VIII Weekly Expenses

Weekly Expenses

Other Deductions From Salary/Wages

How many years have you paid into social security?

Do you have other sources of income?

Additional Income. If not applicable leave blank.

Part III Itemized Deductions from Gross Income

Do you receive income from overtime or part time work?

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Please list off your liabilities.

Please answer the following information about your income tax deductions

Please list off your liabilities.

Please list off your liabilities.

Do you have any debts?

STOCKS

STOCKS

Income Tax Deductions

Please list off your liabilities.

Do you have any of the following: IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans?

Do you have a job?

Employment Information

Do you have children living with you?

How many children do you live with?

What is your home address?

Info

Disclaimer This is not legal advice.

Case Info

Part III Itemized Deductions from Gross Income

What are they?

Savings & Checking Accounts, Money Market Accounts, Certificates of Deposit-which are held individually, jointly, in the name of another person for your benefit, or held by you for the benefit of your minor child(ren):

Do you receive child support or alimony?

Do you receive any of the following?

Any rental income or royalties?

CHILD SUPPORT ALIMONY

Any contributions from household members... explained in detail?

rental and royalties

Are there any other source of income not mentioned here?

CALCULATE Contributions card

Stocks, Bonds, Collections or others?

Savings and Checking Accounts?

DOWNLOAD THE DOCUMENT AND SEND IT IN

Do you own any real estate?

LIBABILITES

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Tax Deferred Annuity Plan(s)

Life Insurance: Present Cash Value

Tell us about your car.

Do you own a motor vehicle?

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Answer the following about any real estate you might own.

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans: Financial Institution or Plan Name and Account Number

Documents

Your Documents

Income Information

We need to ask you about your income now.

Part VIII

Weekly Expenses

Part III

Itemized Deductions from Gross Income

Do you have any of the following:

IRA, Keogh, Pension, Profit Sharing, Other Retirement Plans?

Disclaimer

This is not legal advice.

Part III
Itemized Deductions from Gross Income