Att. 4 Expenses for Dom. Relations Aff. for ______________________ in Case No.__________


Item                    Husband     Wife      Comment

Rent (if no mortgage)   __________  ________  _________________

Food                    __________  ________  _________________

UTILITIES

  Trash Service         __________  ________  _________________

  Newspaper             __________  ________  _________________

  Telephone             __________  ________  _________________

  Natural Gas           __________  ________  _________________

 Electricity            __________  ________  _________________

  Cable                 __________  ________  _________________

  Other __________      __________  ________  _________________

INSURANCE

  Life                  __________  ________  _________________

  Health                __________  ________  _________________

  Vehicle               __________  ________  _________________

  House or Renter's     __________  ________  _________________

  Other __________      __________  ________  _________________

Medical & Dental        __________  ________  _________________

Prescription Drugs      __________  ________  _________________

CHILD CARE

  Work Related          __________  ________  _________________

  Nonwork Related       __________  ________  _________________

Clothing                __________  ________  _________________

School Expenses         __________  ________  _________________

Hair Cut & Beauty       __________  ________  _________________

Car Repair              __________  ________  _________________

Gasoline & Oil          __________  ________  _________________

Pers. Prop. Tax         __________  ________  _________________

MISCELLANEOUS

  Legal Fees            __________  ________  _________________

  ________________      __________  ________  _________________

  ________________      __________  ________  _________________

  ________________      __________  ________  _________________

  ________________      __________  ________  _________________

Total                   __________  ________                                                                    

                                                                Balance    Date

                                                                           Incurred
MORTGAGE PAYMENTS                                       
_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________


VEHICLE PAYMENTS

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________


CREDIT CARD PAYMENTS

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________


OTHER MONTHLY PAYMENTS

_________________      __________  ________  _________________  _________  _________

_________________      __________  ________  _________________  _________  _________

Total                  __________  ________




GRAND TOTAL            __________  ________