Property & Finances

a. General Information

The Order was issued on: Enter the date the support order you want to change was signed by the judge. Use month, day, and year. The Order was issued by: Write the name of the court that made the order you want to change. Located in this County: Write the county where that court is located. Name of Person ordered to pay: Write the full name of the person who was told by the court to make the payments. Total Current Amount Ordered Paid: $ Enter the full dollar amount currently ordered to be paid for all support combined. PER Write how often this amount is paid, such as week or month.

b. Child Support

Child Support $ Enter the dollar amount of the total that is for child support. Child Support per Write how often the child support is paid, such as week or month. Spousal Maintenance/Support $ Enter the dollar amount of the total that is for spousal support, if any. Spousal Maintenance/Support per Write how often the spousal support is paid, such as week or month. Other (i.e. Clearinghouse fee): $ Enter the dollar amount for any other charges, like a clearinghouse fee. Other (i.e. Clearinghouse fee): per Write how often this other amount is paid, such as week or month. Payments in Arrears: $ Enter the dollar amount being paid toward past-due support you owe. Payments in Arrears: per Write how often the past-due payment is made, such as week or month. I listed all sources of my income. Check YES if you wrote down every place your money comes from. If you check NO, explain on a separate page. I attached copies of my two (2) most recent pay stubs. Check YES if you attached your last two pay stubs. If you check NO, explain on a separate page. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. Check YES if you attached the past three years of tax returns plus your W-2 and 1099 forms. If you check NO, explain on a separate page. Name Write the full name of the first person who lives in your home with you.

c. Children's Basic Information

Date of Birth Write the day this person was born. Relationship to you Write how this person is related to you, such as spouse, child, or roommate. Income Write how much money this person earns each month before taxes. Name Write the full name of the second person who lives in your home with you. Date of Birth Write the day this person was born. Relationship to you Write how this person is related to you, such as spouse, child, or roommate. Income Write how much money this person earns each month before taxes. Attorney's Fees paid in this matter $ Write the total dollar amount you have paid your lawyer for this case. Source of funds Tell where the money to pay your lawyer came from, like savings or a loan. Your job/occupation/profession/title: Write your current job or what kind of work you do. Name and address of current employer: Write the name and full address of the company you work for now. Date employment began: Write the date you started this job. Weekly Check this if you get paid once every week. Every other week Check this if you get paid once every two weeks. Monthly Check this if you get paid once a month. Twice a month Check this if you get paid two times each month. Other Check this if you get paid on a different schedule than the choices listed. Other Explain how often you get paid if it is not one of the listed choices. If you are not working, why not? If you have no job, explain why you are not working right now. Previous employer name and address: Write the name and address of the company where you used to work. Previous job/occupation/profession/title: Write the job or kind of work you did at your last job. Date previous job began: Write the date you started your last job. Date previous job ended: Write the date your last job ended. Reason you left job: Tell why you stopped working at your last job. Gross monthly pay at previous job: $ Write how much money you earned each month before taxes at your last job. Year Write one of the last three years from your tax returns. $ Write your total income for that year from your tax return. Year Write another of the last three years from your tax returns. $ Write your total income for that year from your tax return. Year Write the third of the last three years from your tax returns. $ Write your total income for that year from your tax return. year-to-date income): $ Write how much money you have earned so far this year, from January 1 until now. A. High School: Write the name of your high school, how long you went there, the last year you attended, and any diploma you earned. B. College: Write the name of your college, how long you went there, the last year you attended, and any degree you earned. C. Post-Graduate: Write any schooling you did after college, including how long you went and any degree you earned. D. Occupational Training: Write any job or trade training you completed, including how long it took and any certificate you earned. A. Gross salary/wages per month $ Write how much you earn each month before any taxes or other amounts are taken out. Rate of Pay $ Write how much money you are paid at your normal pay rate. Then check the box that shows how often. [ ] hour Check this box if the rate of pay you wrote is for each hour you work. [ ] week Check this box if the rate of pay you wrote is for each week you work. [ ] month Check this box if the rate of pay you wrote is for each month you work. [ ] year Check this box if the rate of pay you wrote is for the whole year. 1. Automobile $ Write the monthly value of a car your employer pays for or provides. Enter 0 if none. 2. Auto expenses, such as gas, repairs, insurance $ Write the monthly amount your employer pays for things like gas, car repairs, or car insurance. Enter 0 if none. 3. Lodging $ Write the monthly value of housing or a place to stay that your employer pays for. Enter 0 if none. 4. Other (Explain) Describe any other costs your employer pays for that are not already listed. 4. Other (Explain) $ Write the monthly value of the other employer-paid cost you described. Enter 0 if none. C. Commissions/Bonuses $ Write the monthly average of any commissions or bonuses you receive. Enter 0 if none. D. Tips $ Write the monthly average of any tips you earn. Enter 0 if none. E. Self-employment Income (See below) $ Write the monthly money you make from working for yourself or running a business. Enter 0 if none. F. Social Security benefits $ Write the monthly amount you receive from Social Security. Enter 0 if none. G. Worker's compensation and/or disability income $ Write the monthly amount you get from workers' compensation or disability payments. Enter 0 if none. H. Unemployment compensation $ Write the monthly amount you receive in unemployment benefits. Enter 0 if none. I. Gifts/Prizes $ Write the monthly average of any money you get from gifts or prizes. Enter 0 if none. Payments from prior spouse Enter the monthly amount of money you get from a former husband or wife, like alimony or spousal support. Rental income (net after expenses) Enter how much money you make each month from renting out property, after you subtract the costs of running it. Contributions to household living expense by others Enter how much money other people give you each month to help pay for living costs in your home. Other (Explain:) Describe any other income you get that is not listed above, such as dividends, pensions, interest, trust income, annuities, or royalties. Other (Explain:) $ Enter the monthly dollar amount for the other income you described. TOTAL: Add up all the income amounts in this section and write the total here. Name, address and telephone no. of business: Write the name of your business, where it is located, and its phone number. Type of business entity: State what kind of business it is, such as a sole proprietorship, partnership, LLC, or corporation. State and Date of incorporation: Write the state where the business was officially formed and the date it was formed. Leave blank if it was never incorporated. Nature of your interest: Explain how you are connected to the business, such as owner, partner, or shareholder. Nature of business: Describe what the business does or what it sells. Percent ownership: Enter what share of the business you own, written as a percentage. Number of shares of stock: Enter how many shares of stock you own in the business, if it has stock. Total issued and outstanding shares: Enter the total number of shares the business has given out to all owners. Gross sales/revenue last 12 months: Enter the total money the business took in over the last 12 months, before any costs are taken out.

d. Health & Medical Support

Drugs and medical supplies Enter the monthly amount you pay out of pocket for medicines and medical supplies after any insurance pays its part. Other Describe any other medical or dental costs you pay that are not covered by insurance. Other Enter the monthly dollar amount for the other medical or dental cost you described. TOTAL: Add up the amounts above and write the total monthly out-of-pocket medical and dental costs. Total monthly child care costs Enter how much you pay each month for child care. Do not count amounts paid by D.E.S. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this first child. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this second child. Name(s) of child(ren) cared for and amount per child: Enter the monthly child care cost for this third child. YES Check this box if your employer lets you pay child care costs with pretax money, like a cafeteria plan. NO Check this box if you do not use an employer pretax plan to pay child care costs.

e. Child Support

Court ordered current child support for child(ren) not common to the parties Enter the monthly child support a court ordered you to pay for children who are not children of you and the other party in this case.

f. Health & Medical Support

Court ordered cash medical support for child(ren) not common to the parties Enter the monthly cash medical support a court ordered you to pay for children not shared with the other party in this case. Amount of any arrears payment Enter the monthly amount you pay toward past-due child support you still owe. Amount per month actually paid in last 12 mos. Enter the amount you actually paid each month over the past year. You must attach proof of payment. Court ordered spousal maintenance/support you actually pay to previous spouse: Enter the monthly amount you actually pay a former spouse because a court ordered it. Leave blank if you do not pay any. For Children (Educational Expense/Special Needs/Other): Enter the monthly amount you spend on unusual costs for your children, like special schooling or special needs care. Explain: Describe what the unusual children's expenses are for, so the court understands the amount above. For Self: Enter the monthly amount you spend on unusual costs for yourself that are not part of normal living expenses. Explain: Describe what your unusual personal expenses are for, so the court understands the amount above. First Mortgage Enter what you pay each month for your first mortgage on your home. Second Mortgage Enter your monthly payment for a second mortgage, if you have one. Homeowners Association Fee Enter the monthly fee you pay to a homeowners association, if any. Rent If you rent your home, enter how much you pay each month. Repair & upkeep Enter what you spend each month to fix and maintain your home. Yard work/Pool/Pest Control Enter your monthly cost for yard care, pool service, or pest control. Insurance & taxes not included in house payment Enter monthly home insurance and property taxes only if they are not already part of your house payment. Other (Explain): Describe any other housing cost not listed above. Other (Explain): $ Enter the monthly amount for the other housing cost you described. TOTAL: Add up all the housing amounts above and enter the total here. Water, sewer, and garbage Enter your monthly cost for water, sewer, and trash service. Electricity Enter how much you pay each month for electricity. Gas Enter your monthly cost for gas service. Telephone Enter how much you pay each month for home phone service. Mobile phone/pager Enter your monthly cell phone or pager bill. Internet Provider Enter how much you pay each month for internet service. Cable/Satellite television Enter your monthly cost for cable or satellite TV. Other (Explain): Describe any other utility cost not listed above. Other (Explain): $ Enter the monthly amount for the other utility cost you described. TOTAL: Add up all the utility amounts above and enter the total here. Food, milk, and household supplies Enter what you spend each month on groceries, milk, and household items. School lunches Enter how much you pay each month for school lunches. Meals outside home Enter your monthly cost for eating out or buying meals away from home. TOTAL: Add up all the food amounts above and enter the total here. Clothing for you Enter how much you spend each month on your own clothes. Uniforms or special work clothes Enter your monthly cost for work uniforms or special clothes needed for your job. Clothing for children living with you Enter how much you spend each month on clothes for children who live with you. Laundry and cleaning Enter your monthly cost for washing clothes or dry cleaning. TOTAL: Add up all the clothing amounts above and write the total here. Car insurance Enter how much you pay each month for car insurance. List all cars and individuals covered: List each car you have and the names of people covered by the insurance. Car payment, if any Enter your monthly car loan or lease payment. Leave blank if you have none. Car repair and maintenance Enter your average monthly cost for car repairs and upkeep, like oil changes or tires. Gas and oil Enter how much you spend each month on gas and oil for your car. Bus fare/parking fees Enter your monthly cost for bus fare or parking. Other (explain): Describe any other travel cost not already listed above. Other (explain): Enter the monthly amount for the other travel cost you described. TOTAL: Add up all the travel and car amounts above and write the total here. School and school supplies Enter your monthly cost for school and school supplies. School activities or fees Enter your monthly cost for school activities or fees. Extracurricular activities of child(ren) Enter your monthly cost for activities outside of school, like sports or music lessons. Church/contributions Enter how much you give each month to your church or charity. Newspapers, magazines and books Enter your monthly cost for newspapers, magazines, and books. Barber and beauty shop Enter your monthly cost for haircuts and beauty shop visits. Life insurance (beneficiary: Write the name of the person who would receive your life insurance money. Life insurance (beneficiary: Enter how much you pay each month for life insurance. Disability insurance Enter how much you pay each month for disability insurance. 9. Recreation/entertainment Enter how much you spend each month on fun activities like movies, hobbies, or sports. 10. Child(ren)'s allowance(s) Enter the total monthly amount you give your children as allowance money. 11. Union/Professional dues Enter how much you pay each month for union membership or job-related professional groups. 12. Voluntary retirement contributions and savings deductions Enter the amount you choose to put into retirement savings each month from your pay. 13. Family gifts Enter how much you spend each month on gifts for family members. 14. Pet Expenses Enter your monthly cost for pets, like food, supplies, and vet visits. 15. Cigarettes Enter how much you spend on cigarettes or tobacco each month. 16. Alcohol Enter how much you spend on alcohol each month. 17. Other (explain): Describe any other monthly expense not already listed above. 17. Other (explain): $ Enter the monthly dollar amount for the other expense you described. TOTAL: Add up all the monthly amounts above and write the total here. Creditor Name Write the name of the company or person you owe money to. Purpose of Debt Briefly explain what this debt was for, like a car loan or credit card. Unpaid Balance Enter the total amount you still owe on this debt. Min. Monthly Payment Enter the smallest amount you must pay on this debt each month. Date of Your Last Payment Enter the date you last made a payment on this debt. Amount of Your Payment Enter how much you paid the last time you made a payment. YES 1. I listed all sources of my income. Check this box if you wrote down every place you get money from. NO 1. I listed all sources of my income. Check this box if you did not list all your income, then explain why on a separate sheet. YES 2. I attached copies of my two (2) most recent pay stubs. Check this box if you included your last two pay stubs with this form. NO 2. I attached copies of my two (2) most recent pay stubs. Check this box if you did not attach your pay stubs, then explain why on a separate sheet. YES 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. Check this box if you attached your last three years of tax returns plus your W-2 and 1099 forms. NO 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. Check this box if you did not attach those tax forms, then explain why on a separate sheet. Name Write the full name of one person who lives with you.

g. Children's Basic Information

Date of Birth Enter the day, month, and year this person was born. Relationship to you Say how this person is related to you, like spouse, child, or roommate. Income Write how much money this person makes each month before taxes. Name Write the full name of another person who lives with you. Date of Birth Enter the day, month, and year this person was born. Relationship to you Say how this person is related to you, like spouse, child, or roommate. Income Write how much money this person makes each month before taxes. Attorney's Fees paid in this matter $ Write the total dollar amount you have paid your lawyer for this case so far. Source of funds Tell where the money came from to pay your lawyer, like savings, a loan, or family help. Your job/occupation/profession/title: Write what you do for work, like your job name or title. Name and address of current employer: Write the name of the place you work and its full street address. Date employment began: Write the date you started working at this job. Weekly Check this if you get a paycheck once every week. Every other week Check this if you get a paycheck once every two weeks. Monthly Check this if you get a paycheck once a month. Twice a month Check this if you get a paycheck two times each month. Other Check this if you get paid on a different schedule than the choices listed. Other Explain how often you get paid if it does not match the other choices. If you are not working, why not? If you do not have a job right now, explain why, like you are disabled or looking for work. Previous employer name and address: Write the name and full address of the last place you worked before your current job. Previous job/occupation/profession/title: Write what you did at your last job, like the job name or title. Date previous job began: Write the date you started your last job. Date previous job ended: Write the date you stopped working at your last job. Reason you left job: Explain why you left your last job, like you quit, were laid off, or got a better job. Gross monthly pay at previous job: $ Write how much you earned each month at your last job before taxes were taken out. Year Write one of the last three years you filed a tax return. $ Write your total income for that year from your tax return. Year Write another of the last three years you filed a tax return. $ Write your total income for that year from your tax return. Year Write the third of the last three years you filed a tax return. $ Write your total income for that year from your tax return. income): $ Write how much money you have earned before taxes from January 1 of this year until today. Gross salary/wages per month Enter your monthly pay before any taxes or deductions are taken out. If your pay changes, use an average month. Rate of Pay $ Enter the dollar amount you are paid at one time, then check the box that shows how often you earn it. [ ] hour Check this box if the rate of pay you entered is the amount you earn each hour. [ ] week Check this box if the rate of pay you entered is the amount you earn each week. [ ] month Check this box if the rate of pay you entered is the amount you earn each month. [ ] year Check this box if the rate of pay you entered is the amount you earn each year. 1. Automobile Enter the monthly value of a car your employer pays for or lets you use. 2. Auto expenses, such as gas, repairs, insurance Enter the monthly amount your employer pays toward your gas, car repairs, or car insurance. 3. Lodging Enter the monthly value of housing or lodging your employer pays for. 4. Other (Explain) Describe any other expense your employer pays for that isn't already listed. 4. Other (Explain) $ Enter the monthly dollar amount of the other employer-paid expense you described. Commissions/Bonuses Enter the monthly amount you earn from commissions or bonuses. If it varies, use an average month. Tips Enter the monthly amount you earn in tips. If it changes, use an average month. Self-employment Income (See below) Enter the monthly income you earn from your own business or working for yourself. Social Security benefits Enter the monthly amount you receive in Social Security payments. Worker's compensation and/or disability income Enter the monthly amount you receive from workers' compensation or disability payments. Unemployment compensation Enter the monthly amount you receive in unemployment benefits. Gifts/Prizes Enter the monthly amount you receive from gifts or prizes. If it varies, use an average month. J. Payments from prior spouse Enter the monthly amount you get from a former husband or wife, like alimony or spousal support. K. Rental income (net after expenses) Enter your monthly rent income after paying costs for the property. List what is left over. L. Contributions to household living expense by others Enter the monthly money others give you to help pay for your home and living costs. M. Other (Explain:) Describe any other income not already listed, such as dividends, pensions, or trust money. M. Other (Explain:) $ Enter the monthly dollar amount for the other income you described. TOTAL: $ Add up all the income amounts above and write the total here. Name, address and telephone no. of business: Write your business name, full address, and phone number. Fill this in only if you work for yourself. Type of business entity: Enter what kind of business it is, such as sole owner, partnership, LLC, or corporation. State and Date of incorporation: Enter the state where the business was formed and the date it was created. Skip if not a corporation. Nature of your interest: Explain your role or share in the business, such as owner or partner. Nature of business: Describe what the business does or what it sells. Percent ownership: Enter the percent of the business that you own, like 100% or 50%. Number of shares of stock: Enter how many shares of stock you own in the business. Skip if it has no stock. Total issued and outstanding shares: Enter the total number of shares the business has given out. Skip if it has no stock. Gross sales/revenue last 12 months: Enter the total money the business made over the last 12 months before any costs.

h. Health & Medical Support

Drugs and medical supplies Enter the monthly dollar amount you pay for drugs and medical supplies after any insurance pays its share. Other Describe any other unpaid medical or dental cost not already listed above. Other Enter the monthly dollar amount for that other medical or dental cost. TOTAL: Add the drugs/supplies amount and the other amount, then write the total here. Total monthly child care costs Enter how much you pay each month for child care. Do not count any amount paid by the Department of Economic Security (D.E.S.). YES Check this box if your employer lets you pay child care costs with pretax money (a cafeteria plan). NO Check this box if you do not use an employer pretax program for child care costs.

i. Child Support

Court ordered current child support for child(ren) not common to the parties Enter the monthly amount a court orders you to pay for children who are not shared with the other party in this case.

j. Health & Medical Support

Court ordered cash medical support for child(ren) not common to the parties Enter the monthly cash medical support a court orders you to pay for children who are not shared with the other party. Amount of any arrears payment Enter the monthly amount you pay toward past-due child support you owe. Amount per month actually paid in last 12 mos. Enter how much you actually paid each month over the past 12 months. Attach proof that you are paying. Court ordered spousal maintenance/support you actually pay to previous spouse: Enter the monthly amount you actually pay a former spouse for spousal support, if a court ordered it. For Children (Educational Expense/Special Needs/Other): Enter the monthly dollar amount you spend on special costs for your children, like school or special needs. Explain: Briefly describe what the children's extra expense is for, such as private school or therapy. For Self: Enter the monthly dollar amount you spend on any unusual or special expenses for yourself. Explain: Briefly describe what your own extra expense is for and why it is unusual. a. First Mortgage Enter how much you pay each month for your first home loan. b. Second Mortgage Enter how much you pay each month for a second home loan, if you have one. c. Homeowners Association Fee Enter your monthly homeowners association fee, if your neighborhood charges one. d. Rent Enter how much rent you pay each month if you do not own your home. 2. Repair & upkeep Enter your monthly cost to fix and maintain your home. 3. Yard work/Pool/Pest Control Enter your monthly cost for yard care, pool service, or bug control. 4. Insurance & taxes not included in house payment Enter monthly home insurance and property taxes only if they are not already part of your house payment. 5. Other (Explain): Briefly describe any other monthly housing cost not listed above. 5. Other (Explain): $ Enter the monthly dollar amount for that other housing cost. TOTAL: Add up all your housing costs above and write the total here. 1. Water, sewer, and garbage Enter your monthly bill for water, sewer, and trash service. 2. Electricity Enter your monthly electric bill. 3. Gas Enter your monthly gas bill. 4. Telephone Enter your monthly home phone bill. 5. Mobile phone/pager Enter your monthly cell phone bill. 6. Internet Provider Enter your monthly internet bill. 7. Cable/Satellite television Enter your monthly cable or satellite TV bill. 8. Other (Explain): Briefly describe any other monthly utility cost not listed above. 8. Other (Explain): $ Enter the monthly dollar amount for that other utility cost. TOTAL: Add up all your utility costs above and write the total here. 1. Food, milk, and household supplies Enter your monthly cost for groceries and household items. 2. School lunches Enter your monthly cost for your kids' school lunches. 3. Meals outside home Enter your monthly cost for eating out at restaurants or fast food. TOTAL: Add up all your food costs above and write the total here. Clothing for you Enter how much you spend each month on clothes for yourself. Uniforms or special work clothes Enter your monthly cost for work uniforms or special clothes needed for your job. Clothing for children living with you Enter how much you spend each month on clothes for the children who live with you. Laundry and cleaning Enter your monthly cost for washing clothes, dry cleaning, or laundromat. TOTAL: Add up all the clothing amounts above and write the total here. Car insurance Enter how much you pay each month for car insurance. List all cars and individuals covered: List each car you own and the names of the people covered by the insurance. Car payment, if any Enter your monthly car loan or lease payment, if you have one. Car repair and maintenance Enter what you spend each month to fix and maintain your car, like oil changes and tires. Gas and oil Enter how much you spend on gas and oil for your car each month. Bus fare/parking fees Enter your monthly cost for bus fare, train, or parking. Other (explain): Describe any other monthly travel cost not listed above. Other (explain): Enter the monthly amount for the other travel cost you described. TOTAL: Add up all the transportation amounts above and write the total here. School and school supplies Enter your monthly cost for school and supplies like notebooks and pens. School activities or fees Enter what you spend each month on school activities or fees. Extracurricular activities of child(ren) Enter your monthly cost for children's activities like sports, music, or clubs. Church/contributions Enter how much you give each month to your church or charity. Newspapers, magazines and books Enter your monthly cost for newspapers, magazines, and books. Barber and beauty shop Enter how much you spend each month on haircuts and salon visits. Life insurance (beneficiary: Write the name of the person who would receive money from your life insurance. Life insurance (beneficiary: Enter how much you pay each month for life insurance. Disability insurance Enter your monthly cost for disability insurance, which pays you if you cannot work. 9. Recreation/entertainment Enter how much you spend each month on fun activities like movies, hobbies, or sports. 10. Child(ren)'s allowance(s) Enter the monthly amount you give your children as spending money. 11. Union/Professional dues Enter the monthly cost of any union fees or job-related professional dues. 12. Voluntary retirement contributions and savings deductions Enter the monthly amount you choose to put into retirement or savings plans. 13. Family gifts Enter how much you spend each month on gifts for family members. 14. Pet Expenses Enter your monthly cost for pets, like food and vet visits. 15. Cigarettes Enter how much you spend each month on cigarettes. 16. Alcohol Enter how much you spend each month on alcohol. 17. Other (explain): Describe any other monthly expense not already listed above. 17. Other (explain): $ Enter the monthly dollar amount for the other expense you described. TOTAL: $ Add up all the amounts on this page and write the total here. Creditor Name Write the name of the company or person you owe money to. Purpose of Debt Explain what this debt was for, like a car, credit card, or loan. Unpaid Balance Enter how much money you still owe on this debt. Min. Monthly Payment Enter the smallest amount you must pay each month on this debt. Date of Your Last Payment Write the date you last made a payment on this debt. Amount of Your Payment Enter how much money you paid on this debt the last time. EMPLOYER* NAME: Write the name of the company or person that pays the support payer, such as their employer. PAYROLL ADDRESS: Write the street address of the payroll or finance office where the order should be mailed. CITY: Write the city for the payroll office address. STATE: Write the state for the payroll office address. ZIP: Write the ZIP code for the payroll office address. EMPLOYER* TELEPHONE: Write the phone number for the employer or payroll office. EMPLOYER* FAX: Write the fax number for the employer or payroll office, if you have it.