Rule 9-203.Financial statements

[caption of case]
FINANCIAL STATEMENT
(Child Support Guidelines)
I, ,........................................................................ state that:

       My name

I am the

          State Relationship (for example, mother, father, aunt, grandfather, guardian, etc.) of the minor child(ren),
          including children who have not attained the age of 19 years, are not married or self-supporting, and are
          enrolled in secondary school:

Name      Date of                                                                         Name  Date of
Name      Birth                                                                           Name  Birth

          Date of                                                                               Date of

                                          Birth                                       Birth

Name                                      Date of             Name                    Date of
                                          Birth                                       Birth

The following is a list of my income and expenses (see below*):

See definitions on other side before filling out.

Total monthly income (before taxes)                                                            $

Child support I am paying for my other child(ren) each month

Alimony I am paying each month to

                                                                 (Name of Person(s))

Alimony I am receiving each month from

                                                                 (Name of Person(s))

For the child or children listed above:

The monthly health insurance premium

Work-related monthly child care expenses

Extraordinary monthly medical expenses

School and transportation expenses

* To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3 and yearly expenses should be
divided by 12. If you do not pay the same amount each month for any of the categories listed, figure what your average monthly
expense is.

I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge,
information, and belief.

Date                                                          Signature

Total Monthly Income: Include income from all sources including self-employment, rent, royalties, business income, salaries,
wages, commissions, bonuses, dividends, pensions, interest, trusts, annuities, social security benefits, workers compensation,
unemployment benefits, disability benefits, alimony or maintenance received, tips, income from side jobs, severance pay, capital
gains, gifts, prizes, lottery winnings, etc. Do not report benefits from means-tested public assistance programs, such as food
stamps or AFDC.

Extraordinary Medical Expenses: Uninsured expenses in excess of $250 in a calendar year for medical treatment, including
orthodontia, dental treatment, vision care, asthma treatment, physical therapy, treatment for any chronic health problems, and
professional counseling or psychiatric therapy for diagnosed mental disorders.

Child Care Expenses: Actual child care expenses incurred on behalf of a child due to employment or job search of either parent
with amount to be determined by actual experience or the level required to provide quality care from a licensed source.

School and Transportation Expenses: Any expenses for attending a special or private elementary or secondary school to meet
the particular needs of the child and expenses for transportation of the child between the homes of the parents.