you and your spouse have? $_ 0.00 Below, state any money you or your spouse have in bank accounts or in any other financial institution.
Financial institution Type of account Amount you have Amount your spouse has -n/a n/a $ n/a $ n/a $ $ $ $
5. List the assets, and their values, which you own or your spouse owns. Do not list clothing and ordinary household furnishings.
Home Other real estate
Value Value n/a
I Motor Vehicle #1 Motor Vehicle #2 Year, make & model -n/a- Year, make & model Value n/a Value "/a
Other assets Description n/a
Value 6. State every person, business, or organization owing you or your spouse money, and the amount owed.
Person owing you or Amount owed to you Amount owed to your spouse your spouse money
n/a $ n/a $ n/a
$ $
$ $
7. State the persons who rely on you or your spouse for support.
Name Relationship Age n/a n/a n/a
8. Estimate the average monthly expenses of you and your family. Show separately the amounts paid by your spouse. Adjust any payments that are made weekly, biweekly, quarterly, or annually to show the monthly rate.
You Your spouse
Rent or home-mortgage payment (include lot rented for mobile home) ft n/a ft n/a Are real estate taxes included? Yes No Is property insurance included? Yes D No
Utilities (electricity, heating fuel, n/a n/a water, sewer, and telephone) $ $
Home maintenance (repairs and upkeep) $ n/a $ n/a
Food $ n/a $ n/a
Clothing $ n/a $ n/a
Laundry and dry-cleaning $ n /?i $ p/s
Medical and dental expenses $ n/a $ n/a You Your spouse
Transportation (not including motor vehicle payments) $ n/a $ n/a
Recreation, entertainment, newspapers, magazines, etc. $ n/a $ n/a
Insui'ance (not deducted from wages or included in mortgage payments)
Homeowner's or renter's $ n/a $ n/a
Life $ n/a $ n/a
Health $ n/a $ n/a
Motor Vehicle $ n/a $ n/a
Other: n/a $ $
Taxes (not deducted from wages or included in mortgage payments)
(specify): n/a $ $
Installment payments
n/a n/a Motor Vehicle $ $
n/a n/a Credit card(s) $ $
n/a n/a Department store(s) $ $
Other: n/a $ $
n/a n/a Alimony, maintenance, and support paid to others $ $
Regular expenses for operation of business, profession, or farm (attach detailed statement) $ n/fl $ n/a
Other (specify): n/a $ $
Total monthly expenses: $ n/a $ n/a 9. Do you expect any major changes to your monthly income or expenses or in your assets or liabilities during the next 12 months?
Yes S No If yes, describe on an attached sheet.
10. Have you paid - or will you be paying - an attorney any money for services in connection with this case, including the completion of this form? Yes Q No
If yes, how much?
If yes, state the attorney's name, address, and telephone number: n/a