declared that the following figures and amounts are accurate to the best of his/her knowledge:
Gross Monthly Income
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
Total Gross Monthly Income
$________________
Itemized Payroll Deductions
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
______________________________________________________
$________________
Total Monthly Deductions
$________________
NET MONTHLY INCOME
$________________
II. LIVING EXPENSES
Amount for Spouse/Parent
Amount for Chilld(ren)
Rent/Mortgage Note
$________________
$________________
$________________
$________________
Automobile Note
$________________
$________________
$________________
$________________
Transportation (Fuel Costs)
$________________
$________________
$________________
$________________
$________________
$________________
Prescriptions
$________________
$________________
$________________
$________________
$________________
$________________
Personal Grooming
$________________
$________________
Electricity
$________________
$________________
THE FAMILY COURT
FORM A, p. 1 of 2
REVISED: NOV 2013
Parent category: Legal
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