Form A
INCOME & EXPENSE AFFIDAVIT
__________________________________ (PETITIONER)
NO: __________________ DIV. ______ THE FAMILY COURT
VERSUS
PARISH OF _____________________
__________________________________ (DEFENDANT)
STATE OF LOUISIANA
PARISH OF ___________________________________ STATE OF LOUISIANA BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in this state and parish, personally appeared ___________________________________, who after being duly sworn, declared that the following figures and amounts are accurate to the best of his/her knowledge: I. INCOME Gross Monthly Income Source
Amount
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________
$________________ $________________ $________________ $________________ $________________
Total Gross Monthly Income
$________________
Itemized Payroll Deductions Source
Amount
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________
$________________ $________________ $________________ $________________ $________________
Total Monthly Deductions NET MONTHLY INCOME
$________________ $________________
II. LIVING EXPENSES Type
Amount for Spouse/Parent
Amount for Chilld(ren)
Rent/Mortgage Note Food Automobile Note Clothing Transportation (Fuel Costs) Medical Dental Prescriptions Household Laundry Personal Grooming Electricity
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
THE FAMILY COURT
FORM A, p. 1 of 2
REVISED: NOV 2013
Gas Water Cable Telephone Cell Phone Educational Expenses: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ Other Expenses: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
TOTAL MONTHLY LIVING EXPENSES
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
III. FIXED DEBT Obligee
_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________
Date of Last Payment
Balance Due
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________
Monthly Payment
$________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________ $________________
TOTAL FIXED DEBT $________________ TOTAL MONTHLY DEBT $________________
___________________________________ AFFIANT SIGNATURE
SWORN TO AND SUBSCRIBED before me this ____ day of ________________________, 20___, at _________________________, Louisiana.
___________________________________ NOTARY PUBLIC
THE FAMILY COURT
FORM A, p. 2 of 2
REVISED: NOV 2013
