Form 4A-212. Interim monthly income and expenses statement.

[For use with Rule 1-122 NMRA] STATE OF NEW MEXICO COUNTY OF ___________________________ ____________________ JUDICIAL DISTRICT _______________________________________, Petitioner, v. No. _________________ _______________________________________, Respondent. SERVE THIS FORM ON THE OTHER PARTY. DO NOT FILE WITH THE COURT. INTERIM MONTHLY INCOME AND EXPENSES STATEMENT1 (fixed percentage for child expenses)1 STATE OF NEW MEXICO ) ) ss. COUNTY OF ) I, ___________________(Petitioner) (Respondent), state under penalty of perjury that the following is true and correct at this time: Petitioner Column 1 Respondent Column 2 Combined Column 3 1. Gross monthly income2 a. Gross monthly wages $__________ $__________ $__________ b. Rental income $__________ $__________ $__________ c. Self-employment income $__________ $__________ $__________ d. Dividends and interest $__________ $__________ $__________ e. Other income $__________ $__________ $__________ 2. Total gross monthly income $__________ $__________ $__________ 3. Payroll deductions3 $__________ $__________ $__________ a. Federal withholding $__________ $__________ $__________ b. State withholding $__________ $__________ $__________ c. Estimated tax payments $__________ $__________ $__________ d. FICA $__________ $__________ $__________ e. Medicare $__________ $__________ $__________ f. Health insurance $__________ $__________ $__________ g. Life and disability insurance $__________ $__________ $__________ h. Union dues $__________ $__________ $__________ i. Mandatory retirement $__________ $__________ $__________ j. Other $__________ $__________ $__________ 4. Total payroll deductions (Add items in #3) $__________ $__________ $__________ 5. Net monthly income (Subtract Line 4 from Line 2) $__________ $__________ $__________ 6. Monthly fixed expenses4: $__________ $__________ $__________ a. Residence5 $__________ $__________ $__________ b. Utilities6 $__________ $__________ $__________ c. Car payments $__________ $__________ $__________ d. Insurance premiums $__________ $__________ $__________ (1) Car or other vehicle $__________ $__________ $__________ (2) Life7 $__________ $__________ $__________ (3) Health7 $__________ $__________ $__________ (4) Homeowners8 or renters $__________ $__________ $__________ (5) Other $__________ $__________ $__________ e. Day care9 $__________ $__________ $__________ f. Credit card payments10 $__________ $__________ $__________ g. Loan payments $__________ $__________ $__________ h. Child support payments11 $__________ $__________ $__________ i. Medical $__________ $__________ $__________ j. Other $__________ $__________ $__________ 7. Total monthly fixed expenses (Add items in #6 and #7)12 $__________ $__________ $__________ 8. Net spendable income (Line 5 minus Line 7) $__________ $__________ $__________ 9. 1/2 of combined net spendable income (1/2 of Line 8 Column 3)13 $__________ $__________ 10. Amount transferred and received14 $__________ $__________ 11. Child support adjustment15 (see table, Use Note 15) $__________ $__________ 12. Total to be transferred16 $__________ $__________ I, _______________________, affirm under penalty of perjury under the laws of the State of New Mexico that I am the [ ] Petitioner (or) [ ] Respondent in the above-entitled cause, and I know and understand that the contents of this Statement are true to the best of my knowledge and belief. ______________________________________ Signature Date