PARENT’S FINANCIAL STATEMENT

CHILD’S FULL NAME: CASE NO.:

PARENT’S FULL NAME: AGE:

*If both parents still together, only fill out one statement; otherwise, fill out one for each parent.

I.	INCOME

A. EMPLOYMENT

I am employed as a at . My salary is $ take home per hour/week/month.

My spouse is employed as a at . at a salary of $ take home per hour/week/month.

B. OTHER INCOME

Child support	$

Social Security	$

Welfare	$

AFDC	$

Food Stamps	$

Pension	$

Unemployment	$

Worker’s Comp.	$

Other	$

TOTAL INCOME	$

II.	EXPENSES

RENT/MORTGAGE	$

UTILITIES (gas, elec, water, phone)	$

CAR PAYMENT	$

FOOD	$

CLOTHING	$

OTHER	$

TOTAL EXPENSES	$

III.	PROPERTY OWNED

CAR MAKE & MODEL:	Value: $

OTHER REAL ESTATE:	Value: $

FURNITURE:	Value: $

TV / STEREO:	Value: $

SAVINGS ACCT:	Value: $

JEWELRY:	Value: $

TOTAL VALUE OF PROPERTY OWNED	$

IV.	OTHER INFORMATION

NAMES AND AGES OF ALL PERSONS LIVING IN YOUR HOME:

NAME: AGE:

NAME: AGE:

NAME: AGE:

NAME: AGE:

NAME: AGE:

NAME: AGE:

THE STATE OF TEXAS	§

COUNTY OF WICHITA	§

I certify that the above information is true and correct and that the Juvenile Court may consider information instead of my testimony in determining any amount of money that I may be ordered to pay.

SIGNED THIS day of , ___________

(Day) (Month) (Year)

X

SUBSCRIBED AND SWORN to before me on the day of , , to certify which witness my hand and official seal.

Notary Public, State of Texas

Indigent

Non-Indigent

Judge’s Signature