Local Rule - State of Indiana
Local Rule - State of Indiana
Local Rule - State of Indiana
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Employer Dates <strong>of</strong> employment Compensation (per wk/mo/yr)C. INCOME SUMMARYL. GROSS WEEKLY INCOME FROM: Salaryand wages, including commissions, bonuses,allowances and over-time $Note: If paid monthly, determine weekly income bydividing monthly income by 4.3Pensions & RetirementSocial SecurityDisability and unemployment insurancePublic Assistance (welfare, AFDC payments etc.)Food stampsChild support received for any child(ren) not subjectto this actionDividends and InterestRents receivedIncome from present spouse/relationshipAll other sources (specify)TOTAL GROSS WEEKLY INCOME $ATTACH COPIES OF:Last two Federal and <strong>State</strong> Income Tax ReturnsFive <strong>of</strong> your most recent payroll stubsIII. HEALTH INSURANCE INFORMATIONName and address <strong>of</strong> health care insurance company:22