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Missouri Statement of Income and Expenses Form

To help spouses involved in a divorce case and the court overlooking that case to decide the amount of money that every party involved in the divorce (if any) should receive, the Missouri Statement of Income and Expenses Form can be used.

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Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	1 of 6 	
 	
 	
 	
IN THE CIRCUIT COURT O	F ____	___	___	___	___	__	_____	__,	 M	ISSOURI 	
 
 
In r	e the	 Mar	riage o	f  	 	
 	 	_________________	 	_____________	 	__________________	__ _________	  	(First) 	(Middl	e) 	(Las	t) 	(Jr./Sr./III)  	
Petitioner	, 	 	Case N	o. _______	____	_ 	
 	 	 	
-and	- 	 	
 	 	Division N	o. _________	___	 	_________________	 	_____________	 	__________________	__ _________	  	 	(First) 	(Middl	e) 	(Las	t) 	(Jr./Sr./III)  	
Respondent	. 	 	
    	
 
 	
Statem	ent of I	ncom	e 	and E	xpenses	 	
 	
Are you	 Petition	er or	 the R	espon	den	t?	 (Check one o	f these b	oxes	) 	
 	
  I am the	 Petitio	ne	r.  (	The pa	rty th	at filed the	 or	igina	l pe	tition)	 	
 	
  I am the	 R	esponde	nt.  (The pa	rty tha	t answers the or	igina	l pe	tition f	iled by	 hi	s or he	r spous	e) 	
 
Are you	 the H	usband 	or the Wi	fe?	
 (Chec	k one of the	se b	oxes	) 	
 	
  I am the	 Wi	fe. 	
 	
  I am the	 H	usba	nd.	 	
 
You m	ust fill in t	he	 amount	s for bot	h y	ou a	nd y	our	 hu	sba	nd o	r w	ife.  I	f you do not	 know	 the	 exa	ct 	
amount	 for your	 spous	e, y	ou s	hou	ld estim	ate the	 amount	 to	 th	e be	st o	f your	 ability	.  DO NOT	 LEAV	E 	
THE	SE AM	OUN	TS B	LANK	. 	
 
Wh	y d	oe	s the cou	rt r	equire this infor	m	ation	?   	
The	 amount	 of	 inc	om	e and e	xpe	nses of each p	arty is significant in a	 dissolution o	f m	arriag	e pro	ceed	ing	 	
for 	sev	eral reason	s.  F	irst, if there are une	manc	ipated c	hildren 	bor	n of 	the	 m	arriag	e, t	he	 cou	rt m	ust 	
de	termine	 the amount	 of	 child suppo	rt to b	e pa	id by	 on	e pa	rty to t	he	 othe	r pa	rty.  Missour	i Sup	reme C	our	t 	
Rule 88.	01 a	nd F	orm 14 pr	ov	ide	 the	 ba	sis for the	 calculation 	of a pr	esum	ed a	mount	 of	 suppo	rt.  The	 	
amount	s you e	nter on 	this “Statem	ent	 of 	Inc	om	e and E	xpe	nses” m	ay be	 us	ed by	 the cou	rt in c	alculating	 	
the	 amount	 of child s	upp	ort. 	
 	
Form CAFC050	-04/01/200	9 	 	 	
(County where court is located)

Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	2 of 6 	
 	
 	
Second, 	the	 amount	s entered on t	his “Statement of Inc	om	e and E	xpe	nses” m	ay be	 us	ed by	 the cou	rt in 	
de	termining	 w	he	the	r on	e party is entitled t	o m	aintena	nce.  M	aintenanc	e is spou	sal suppo	rt paid by	 one	 	
pa	rty to the	 ot	her.  Ma	inten	anc	e w	as f	ormerly cal	led 	alimony	.  If a pa	rty doe	s no	t recei	ve m	aintena	nce a	t 	
the	 time of	 dissolution, a	nd	 the	 judg	ment is no	t sub	ject to m	odi	fication,	 the pa	rty cannot	 com	e ba	ck to 	
cour	t to reque	st m	aintena	nc	e in the	 future.  A pa	rty m	ay be	 ent	itled t	o m	ainten	anc	e i	f the	 pa	rty lack	s 	
sufficient prope	rty to p	rov	ide	 for hi	s or	 he	r reason	abl	e ne	eds	 or 	if the	 party is un	able to s	up	por	t hi	m or	 	
he	rself throug	h a	pp	ropr	iate employm	ent.  S	ee R	SMo. 	§452.335.	 	
 
Third, 	inc	om	e and e	xpe	nse amount	s m	ay be	 us	ed by	 the	 cou	rt in de	termining	 the	 amount	 of	 attorne	y’s 	
fees 	to b	e aw	arde	d a pa	rty.  The cou	rt has the	 pow	er to or	de	r one	 pa	rty to pa	y the othe	r pa	rty’s attorney’s 	
fees.	  RSMo. §452.35	5. 	
 
If you c	annot	 accu	rately est	imate t	he	 incom	e and e	xpe	nses o	f your	 sp	ous	e, there are m	ethods	 av	ailable to 	
discov	er exa	ctly how	 m	uc	h your	 spous	e earns and s	pe	nds	.  Th	ese m	ethods	 are us	ua	lly be	yond t	he	 ability 	
of non-	lawyers, a	nd 	it is strong	ly sugg	ested t	hat if you 	do not	 ha	ve an a	ccurate estimate of	 how	 m	uc	h 	
your	 spous	e earns and s	pends, a	nd 	the	se issues w	ou	ld be	 relevant to y	our	 case, then y	ou s	houl	d c	on	tact a 	
law	yer to a	ssist you.	 	
 
The	 cou	rt m	ay	 requi	re y	ou 	to f	ile a m	ore com	plete “S	tatem	ent	 of Inc	ome and E	xp	ens	es”.  	This w	ou	ld 	
inc	lude	 a m	ore de	tailed 	ana	lysis o	f incom	e and e	xp	ens	es.	 	
   	Please type or print clearly in black ink.  A	 copy of this form M	UST be sent to your spouse.  The information 	
in this form is open to the public. 	
 	All p	leadings that you file with the court are required to contain the case number and division number (if 	
applicable).  F	ailure to include the case number on your pleading m	ay cause your pleading to be filed in the 	
wrong case.  If your case has not yet been filed, then you do not have to enter the cause number on this form. 	
 
 
You m	us	t fill in a	ll bl	ank	s for	 H	us	band 	and	 W	ife w	ith an	 am	ount even	 if the 	
am	ount	 is ze	ro.	   	
 
1.  INCO	ME 	WIFE 	HUS	BAND	 	
MONT	HL	Y G	RO	SS INCO	ME – Enter one	-twelfth of	 the p	arty’s ye	arly 	
gros	s inc	om	e (Inc	ome bef	ore an	y tax	es	 or	 other withh	olding)	.  This is 	
the am	ount	 of	 m	one	y you	 earn B	EFORE an	y deduc	tions or tax	es	. 	
 	 	
     Instructions to Q	uestion 1 -  “Gross incom	e” include	s, but	 is not	 limited t	o, salaries, wages	, com	mission, dividends	, severance pa	y, 	pens	ions	, interest, trust incom	e, annui	ties, par	tner	ship di	stributions	, social security benef	its, retirem	ent	 benef	its, workers’ com	pens	ation 	benef	its, unem	ployment	 com	pens	ation 	benef	its, disabi	lity insuranc	e benef	its, veterans’ benef	its, and m	ilitary allowanc	es for subs	istenc	e 	and quar	ter. 	     Overtime c	om	pens	ation, bonu	ses, ear	ning f	rom	 secondar	y em	ployment	, recurring c	api	tal gai	ns, prizes, retained ear	nings and 	signi	ficant em	ployment	-related be	nef	its may be 	included i	n whol	e or	 in par	t. 	     If a par	ty is unem	ployed or	 found t	o be	 under	em	ployed,	 “gross incom	e” may be ba	sed on i	mput	ed incom	e. 	     Excluded	 from	 “gross incom	e” is tem	por	ary as	sistance for needy	 fam	ilies (TANF) payment	, Medi	caid benef	its, suppl	em	ent	al security 	incom	e (SSI) benef	its, food 	stam	ps, gener	al assistance benef	its, other publ	ic assistance benef	its hav	e eligibility bas	ed 	on incom	e and 	child suppor	t received f	or children 	not	 the subj	ect of this proceedi	ng. 	     If a par	ty receives rent	s or royalties or is self-em	ployed,	 in a 	sole propr	ietorship, or bu	siness with joint owner	ship, “gross incom	e” is 	gross receipts minus the or	dinar	y and nec	essary expen	ses incurred 	to pr	oduc	e such receipts.  Depr	eciation,	 investment	 tax credi	ts and 	other	 nonc	ash reduc	tion o	f gross receipts may be e	xcluded f	rom	 such or	dinar	y and ne	cessary expen	ses. 	
 
 	
Form CAFC050	-04/01/200	9

Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	3 of 6 	
 	
 	
 
2.  MAINTEN	ANCE R	EC	EIVED	 	WIFE 	HUS	BAND 	
A.  M	AINTEN	AN	CE R	EC	EIVED	 EAC	H MONTH IN THIS C	AS	E – 	
Thes	e ar	e s	am	e nu	mber	s from	 Li	ne 6A	 in di	fferent	 colum	ns	 	
 	 	
B.  M	AINTEN	AN	CE R	EC	EIVED	 EAC	H MONTH FROM O	THER	 	
CASES	 	
 	 	
C.  T	OTAL	 M	AINTEN	AN	CE R	EC	EIVED	 EAC	H M	ONTH – Enter the 	
total m	ont	hly am	ount	 of	 cour	t or	der	ed m	ainten	anc	e t	hat eac	h par	ty 	
ac	tual	ly rec	eives	.  (Line A plus	 Line 	B) 	
 	 	
 Instructions	 to Q	ues	tion 	2 – This amount	 refers to maintenanc	e that either	 par	ty receives.  The am	ount	 of maintenan	ce to be pai	d by	 	either	 Husband or	 Wife shoul	d be i	ncluded i	n your	 an	swer to Ques	tion 6.	  LINE C SHOULD	 BE THE SUM OF LINE A AND LINE B.   	   
 
 
3.  C	HILD SUPPORT	 RE	CEIVED F	OR 	UNE	MANCI	PATED 	
CHI	LDRE	N NO	T OF THIS M	ARRI	AGE 	WIFE 	HUS	BAND 	
How m	an	y children d	oes	 eac	h par	ty hav	e i	n h	is or	 her	 cus	tod	y tha	t 	
are not	 the	 subj	ec	t of	 this proc	eedi	ng?	 	
 	 	
CHI	LD 	SUPPORT	 RE	CEIVED 	EACH	 M	ONT	H F	OR 	
UNE	MANCI	PATED CHI	LDRE	N NO	T OF THIS M	AR	RIAG	E – Enter 	
the m	ont	hly am	ount	 of	 an	y child supp	ort that eac	h par	ty ac	tually 	
rec	eives	 for unem	anc	ipat	ed c	hildren	 not	 of	 this m	arriage.	 	
 	 	
 Instructions	 to Ques	tion 3 	– The 	first par	t of this ques	tion a	sks you for the num	ber	 of children 	in eac	h person’s custody that	 are not	 	children 	involved 	in this case.  The second	 par	t of this que	stion refers to child suppor	t that either	 par	ty receives from	 som	e third per	son 	not	 a par	ty to this proceedi	ng.  Normally this would be 	child suppor	t received by	 Husband or	 Wife for children 	from	 a pr	evious marriage 	or relationship.  THIS AMOUNT	 DOES NO	T INCL	UDE	 CHI	LD SUPPORT	 PAID F	OR T	HE UNE	MANCIPATED CHI	LDRE	N O	F THIS 	MARRI	AGE.   	
 
 
 
4.  T	OTAL M	ONT	HLY INCO	ME 	WIFE 	HUS	BAND 	
 
TOTAL I	NCOME	 	 	 	
 Instructions	 to Q	ues	tion 	4 – Enter the 	total of the am	ount	s you ent	ered i	n Q	uestions 1, 2c and 3	. 	
 
 
5.  O	THE	R CHI	LD 	SUPPORT	 O	BL	IGATIONS	 FOR 	
UNE	MANCI	PATED CHI	LDRE	N T	HAT ARE NO	T OF THIS 	
MARRI	AGE 	
WIFE 	HUS	BAND 	
OTHE	R CHI	LD 	SUP	PORT	 O	BLIGATIONS	 EAC	H M	ONTH – Enter 	
the m	ont	hly am	ount	 of	 an	y other	 cour	t or	 adm	inistrative or	der	 for child 	
suppor	t to t	he ex	tent of	 the	 am	ount	s ac	tual	ly be	ing	 pa	id t	oward t	he 	
current	 supp	ort of	 an	y child not	 the s	ubjec	t of	 this pr	oc	eed	ing.	 	
 	 	
 Instructions	 to Q	ues	tion 	5 -  Enter the am	ount	 of any	 cour	t order	ed 	child s	uppor	t that is actual	ly bei	ng p	aid by	 one of	 the 	par	ties for 	unem	anc	ipat	ed 	children 	not	 of this marriage t	hat	 are no	t in that	 par	ty’s custody	.  	
 
 
Form CAFC050	-04/01/200	9

Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	4 of 6 	
 	
 	
 
6.  M	AINTENAN	CE PAID 	WIFE 	HUS	BAND 	
A.  M	AINTEN	AN	CE P	AID EAC	H M	ONTH IN THIS C	ASE	 – Thes	e ar	e 	
same num	ber	s from Li	ne 2	A in d	ifferent	 colum	ns	 	
 	 	
B.  M	AINTEN	AN	CE P	AID EAC	H M	ONTH IN O	THER	 CAS	ES 	 	 	
C.  T	OTAL M	AINT	ENA	NC	E PAID 	EACH 	MONT	H – Enter the t	otal 	
mont	hly am	ount	 of	 cour	t order	ed m	aintenanc	e t	hat each par	ty 	
ac	tual	ly pa	ys for current	 m	aintena	nc	e.  (Line A	 plus	 Line B	) 	
 	 	
 Instructions to Ques	tion 6	 – This amount	 refers to maintenanc	e that either	 par	ty pay	s.  The am	ount	 of maintenanc	e to be r	eceived b	y 	either	 Husband or	 Wife shoul	d be i	ncluded i	n your	 an	swer to Ques	tion 2.	 	
 
 
 
NO	TE:  Q	ue	stions	 7	 thr	ough 1	0 appl	y onl	y if the	re a	re une	m	anc	ipa	ted c	hi	ldr	en of	 	
th	is m	arriage	.  If the	re a	re no une	m	ancipa	ted c	hi	ldr	en of	 thi	s m	arriage	, the	n y	ou 	
do not	 ha	ve to a	nswer que	stions	 7 thr	ough 1	0 incl	usive	.  Y	ou m	ust still a	nswe	r 	
Que	stion	s 11 an	d 12	. 	
 
 
7.  CHI	LD C	ARE CO	STS FOR UNE	MANCI	PATED CH	ILDRE	N O	F 	
THIS M	ARRI	AGE 	WIFE 	HUS	BAND 	
CHI	LD C	ARE CO	STS FOR UNE	MANC	IPATED CHI	LDRE	N O	F THIS 	
MAR	RIAG	E EACH M	ONT	H – If ther	e are u	nem	anc	ipated c	hildren 	of 	
this m	arriage,	 enter the 	mont	hly am	ount	 of	 work-related c	hild c	are 	
co	sts inc	urred b	y eac	h p	arent	 as	 a r	es	ult of	 hi	s or	 her	 em	ployment	. 	
 	 	
 Instructions	 to Ques	tion 7	 -  Do no	t ans	wer this que	stion unl	ess you 	hav	e unem	anc	ipat	ed 	children o	f this marriage.	 	     Enter the m	ont	hly am	ount	 of an	y reas	onabl	e work-related 	child care c	osts incurred or	 to be 	incurred by	 each par	ent	 for the 	unem	anc	ipat	ed c	hildren of	 this marriage.	 	     It is preferabl	e to include 	the r	easonabl	e work-related child care c	osts of the par	ent	 en	titled to receive s	uppor	t in the 	calculation o	f 	the 	presum	ed c	hild suppor	t am	ount	 pur	suant	 to Form 14.  Include a	bov	e O	NLY the am	ount	s you 	intend to include 	in your	 Form 14 	child 	suppor	t calculation. 	     However, the w	ork-related child c	are costs may be 	excluded 	from calculation o	f the pr	esum	ed 	child s	uppor	t am	ount	 if an e	vent	 that	 	will signi	ficant	ly affect the 	am	ount	 pai	d for work-related child c	are, such a	s a child’s ent	ry into school	, will oc	cur with pr	edi	ctabi	lity within 	a s	hor	t per	iod of	 time. 	 
 
 
8.  HEALTH I	NS	UR	ANCE	 CO	STS FOR UNE	MANCI	PATED 	
CHI	LDRE	N O	F THIS M	ARRI	AGE 	WIFE 	HUS	BAND 	
HEA	LTH I	NS	UR	ANC	E CO	STS FOR UNE	MANCIPATED CHI	LDR	EN 	
OF THIS M	AR	RIAG	E EACH M	ONT	H – If ther	e ar	e un	em	anc	ipat	ed 	
children of	 this m	arriage,	 enter the mont	hly am	ount	 of	 hea	lth 	
ins	uranc	e cos	ts for thes	e c	hildren 	on	ly. 	
 	 	
 Instructions	 to Ques	tion 8	 – Do not ans	wer this que	stion unl	ess you 	hav	e unem	anc	ipat	ed 	children o	f this marriage.	 	     Enter the m	ont	hly am	ount	 of an	y prem	ium	 pai	d to be pai	d or	 deduc	ted or	 to be deduc	ted 	by an em	ployer from	 gross mont	hly incom	e 	for heal	th insuranc	e pol	icies for the unem	anc	ipat	ed 	children 	of this marriage	. 	     Thes	e am	ount	s shoul	d be	 included 	on F	orm 14,	 Line 6c	. 	
 
 
Form CAFC050	-04/01/200	9

Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	5 of 6 	
 	
 	
 
9.  UNCO	VERE	D 	EXTRAORDI	NARY	 MEDICAL	 CO	STS FOR 	
UNE	MANCI	PATED CHI	LDRE	N O	F THIS M	ARRI	AGE 	WIFE 	HUS	BAND 	
UNCO	VERE	D EX	TRAO	RDINAR	Y MED	ICAL	 COST	S FOR 	
UNEM	AN	CIPAT	ED	 CHI	LDRE	N O	F THIS M	AR	RIAG	E EAC	H 	
MO	NTH– If ther	e ar	e unem	anc	ipated	 children	 of	 this m	arriage	, en	ter 	
the m	ont	hly am	ount	 of	 m	edi	cal and/	or de	ntal ex	pens	es	 not	 covered 	
by hea	lth ins	uranc	e f	or the	se c	hildren 	onl	y. 	
 	 	
 Instructions	 to Ques	tion 9	 – Do not ans	wer this que	stion unl	ess you hav	e unem	anc	ipat	ed c	hildren 	of this marriage.	 	     Enter the m	ont	hly am	ount	 of an	y uni	nsured ex	traor	dinar	y medi	cal costs pai	d or	 to be pai	d b	y the 	par	ent	 by	 agr	eem	ent	 or pur	suant to 	cour	t order	 for the unem	anc	ipat	ed 	children of	 this marriage.	  Include 	abov	e O	NLY the am	ount	s you i	ntend t	o include 	in your	 Form 14 	child s	uppor	t calculation.	 	     “Extraor	dinar	y medi	cal costs” are pr	edi	ctabl	e and r	ecurring,	 such as expens	es for dent	al treat	ment	, orthodont	ic treat	ment	, asthm	a 	treat	ment	 and ph	ysical ther	apy	.  Medi	cal and	 dent	al expens	es incurred 	for singl	e o	ccurrenc	e illnesses or injuries that	 are not	 covered 	or 	fully pai	d under	 an	y heal	th insuranc	e pol	icy shoul	d be handl	ed by	 separ	ate or	der	 and s	houl	d not	 be	 included abov	e.  	     “Uninsured 	medi	cal costs” are reas	onabl	e and ne	cessary medi	cal and dent	al expen	ses, as def	ined 	by section 213	 IRC, incurred 	for 	the c	hildren 	who ar	e the 	subj	ect of this proceedi	ng,	 to the 	extent	 that the uni	nsured por	tion 	of such ex	penses, includi	ng an	y dedu	ctibles 	and c	o-pay	ments, ex	ceeds	 $250.	00 per	 year	 per	 child.    See Form 14,	 Line 6d	, Com	ment	 A. 	
 
 
 
10	.  EXT	RAORDINARY EX	PEN	SES O	F UNE	MANCI	PATED 	
CHI	LDRE	N O	F THIS M	ARRI	AGE 	WIFE 	HUS	BAND 	
EX	TRAO	RDINAR	Y EX	PEN	SE	S O	F UNEM	AN	CIPAT	ED CHI	LDRE	N 	
OF THIS M	AR	RIAG	E EACH M	ONT	H – If ther	e ar	e un	em	anc	ipat	ed 	
children of	 this m	arriage,	 enter the mont	hly am	ount	 of	 an	y 	
ex	traor	dinar	y ex	pe	ns	e f	or thes	e c	hildren o	nly. 	
 	 	
 Instructions	 to Ques	tion 10	 – Do not ans	wer this que	stion unl	ess you hav	e unem	anc	ipated 	children of	 this marriage.	 	     Enter the m	ont	hly am	ount	 of an	y other	 ex	traor	dinar	y child-rear	ing 	costs pai	d or	 to be	 pai	d b	y the 	par	ent	 by	 agr	eem	ent	 or pur	suant	 to 	cour	t order	 for the unem	anc	ipat	ed 	children of	 this marriage.	  Include 	abov	e O	NLY the am	ount	s you i	ntend t	o include 	in your	 Form 14 	child s	uppor	t calculation.	 	     “Other	 extraor	dinar	y child-rear	ing c	osts” may include	, but	 are not	 limited 	to, po	st-secondar	y educ	ational	 ex	pens	es and	 private or	 	par	ochial elem	ent	ary, middl	e and 	high 	school	 expens	es, the cost of tutoring 	sessions	, spec	ial or private elem	ent	ary and 	secondar	y 	school	ing to meet	 the par	ticular ed	ucational	 needs	 of a child, cam	ps, lessons, travel and	 other	 activities intended 	to enhanc	e the 	athletic, social or cultural de	velopment	 of a child. 	     An or	der	 may include 	the cost of tuition,	 room	 and boar	d, boo	ks, fees	 and	 other	 reasonabl	e and ne	cessary ex	pen	ses.  In 	det	ermining t	he 	am	ount	 of these e	xpens	es, schol	arships, grant	s, stipends	 and o	ther	 cost-reduc	ing 	progr	am	s availabl	e to the 	child 	shoul	d be c	ons	ider	ed.”  Form 14,	 Line 	6e,	 Com	ment	 A 	 
 
 
11	.  O	THER	 M	ONTHLY EXPEN	SES	 	WIFE 	HUS	BAND 	
 
OTHE	R M	ONT	HL	Y EXPENS	ES -  	 	 	
 Instructions	 to Ques	tion 11	 – Enter the 	total am	ount	 of all other	 mont	hly expens	es no	t listed 	abov	e.  This include	s the follow	ing:	  Rent	 or 	mortgage pay	ment	s, hom	e m	aintenanc	e, condom	inium	 or subdi	vision fees	, ga	s, electric, water, teleph	one,	 trash service, sewer, cabl	e 	television, internet	 service, hom	e s	ecurity, gas	 and 	oil for autom	obi	les, aut	om	obi	le m	aintenanc	e, taxes and l	icenses for aut	omobi	le, 	pay	ment	s on	 aut	om	obi	le loan	s, life insuranc	e, heal	th insuranc	e (other than heal	th insuranc	e for unem	anc	ipat	ed children 	of this 	marriage)	, disabi	lity insuranc	e, au	tom	obi	le insuranc	e, pens	ion pay	ment	s, installment	 loan 	payment	s, chur	ch and c	har	itabl	e 	cont	ribut	ions, food	, clothing, medi	cal and den	tal expens	es, recreat	ion,	 laundr	y and 	cleani	ng,	 per	sonal	 care, edu	cational	 ex	pen	ses, 	other	 trans	por	tation 	costs, uni	on d	ues	, addi	tional	 tax liabi	lity, gifts, vacations, new	spaper	s and ot	her	 per	iodi	cals, pet	 expens	es, 	couns	eling, and 	any other	 miscellaneous	 ex	pen	ses not	 listed abov	e. 	 
 
Form CAFC050	-04/01/200	9

Statem	ent	 of	 Inc	om	e and E	xpens	es	 - Page 	6 of 6 	
 	
 	
 
12	.  T	OTAL EX	PE	NSES	 	WIFE 	HUS	BAND 	
TOTAL MO	NTHLY	 EX	PEN	SE	S 	 	 	
 Instructions	 to Q	ues	tion 	12 - Enter the 	total of the am	ount	s you ent	ered on Q	ues	tions	 5 through 	11 inclusive. 	
 
 
I certify un	der	 oath that	 I have given	 m	y spo	us	e a c	opy of	 this Statem	ent	 of	 Inc	om	e an	d E	xpens	es	 	
pur	suant	 to Mi	ssour	i Supreme C	our	t Rule 43.	01(	d) by: (You 	MUST chec	k at least ONE of the follow	ing four	 boxes) 	
 	Serving a c	opy with t	he pe	tition	. 	 	Mai	ling a	 copy t	o my spous	e or	 his or	 her	 attorney on 	____	___	___	__	___,	 20	___	__ at	 the 	
following addr	es	s: 	 	__________________	_________	__________________	_________	________________	 	(Street) 	 	__________________	_______	 	__________________	 	______________	 	(City) 	 	 	 	(State) 	 	 	(Zip) 	
 	
 	Hand	ing	 a c	op	y to m	y spou	se or	 hi	s or	 her	 attorne	y on 	____	___	___	__	___,	 20	___	__. 	 	Sen	ding a	 cop	y to m	y spou	se or	 hi	s or	 her	 at	torne	y by fax	 to ____	___	___	__	___	__	__ (telephone 	
num	ber	) on 	___	___	___	___	___,	 20__	___	 at	 ___	___	___	__	_ (time	). 	
 
 Instructions	:  The following information MUST be filled in before a notary public.  This Statement of Inco	me and Expense is required t	o be ve	rified 	before a notary public.  The “Affiant” is the per	son that is completing this docu	ment.  	
 
COUNTY O	F ________	__	 	) 	
 	 	 	 	)  ss.	 	
STATE O	F __________	__	 	) 	
 
 
Affiant	, of	 lawful ag	e, being dul	y sworn on	 hi	s or her	 oath, states	 that he or	 she 	is the 	affiant	 nam	ed 	
her	ein a	nd t	hat	 the f	ac	ts stated 	in this Statem	ent	 of	 Inc	ome and 	Expens	es	 are t	rue ac	cording t	o h	is or	 her	 	
bes	t know	led	ge 	and	 be	lief. 	
 
 
►	_____	___	___	___	___	__	____	___	___	__	___	 	____	___	___	__	___	___	___	_____	___	___	__	 	
     	Affiant	 – SIGN HE	RE	 	 	 	Affiant	 – PRINT	 YOUR N	AME H	ERE 	
 
Subs	cribed a	nd s	worn t	o this ___	__ 	da	y of	 ___	__	___	_____	___	__,	 20	___	_. 	
 
____	___	___	__	___	___	___	___	 	
Notary Publ	ic 	
 
My C	om	mission E	xpires	: 	
 
____	___	___	__	___	___	___	 	
 
Form CAFC050	-04/01/200	9
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