FINANCIAL STATEMENT OF
(General)
(Md Rule 9-203(a))
You must file a Notice Regarding Restricted Information Pursuant to Rule 20-201.1 (form MDJ-008)
with this submission.
Children
Age
MONTHLY EXPENSES
ITEM
SELF
CHILDREN
TOTAL
A. PRIMARY RESIDENCE
Mortgage
Insurance (homeowners)
Rent/Ground Rent
Taxes
Gas & Electric
Electric Only
Heat (oil)
Telephone
Trash Removal
Water Bill
Cell Phone/Pager
Repairs
CIRCUIT COURT FOR
City/County
Located at
Case Number
,MARYLAND
Court Address
vs.
Defendant
Plaintiff
Street Address
Street Address
City, State, Zip
Telephone
City, State, Zip
Telephone
Name
This form contains Restricted Information.
CC-DR-031 (Rev. 08/2024)
Page 1 of 7
FISTA
E-mail
E-mail
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CC-DR-031 (Rev. 08/2024) Page 2 of 7 FISTA
Lawn & Yard Care (snow removal)
Replacement Furnishings/Appliances
Condominium Fee (not included elsewhere)
Painting/Wallpapering
Carpet Cleaning
Domestic Assistance/Housekeeper
Pool
Other:
SUB TOTAL
B. SECONDARY RESIDENCE
(i.e. Summer Home/Rental)
Mortgage
Insurance (homeowners)
Rent/Ground Rent
Taxes
Gas & Electric
Electric Only
Heat (oil)
Telephone
Trash Removal
Water Bill
Cell Phone/Pager
Repairs
Lawn & Yard Care (snow removal)
Replacement Furnishings/Appliances
Condominium Fee (not included elsewhere)
Painting/Wallpapering
Carpet Cleaning
Domestic Assistance/Housekeeper
Pool
Other:
SUB TOTAL
C. OTHER HOUSEHOLD NECESSITIES
Food
Case Number
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Drug Store Items
Household Supplies
Other:
SUB TOTAL
D. MEDICAL/DENTAL
Health Insurance
Therapist/Counselor
Extraordinary Medical
Dental/Orthodontia
Ophthalmologist/Glasses
Other:
SUB TOTAL
E. SCHOOL EXPENSES
Tuition/Books
School lunch
Extracurricular activities
Clothing/Uniforms
Room & Board
Daycare/Nursery School
Other:
SUB TOTAL
F. RECREATION & ENTERTAINMENT
Vacations
Videos/Theater
Dining Out
Cable TV/Internet
Allowance
Camp
Memberships
Dance/Music Lessons etc.
Horseback Riding
Other:
SUB TOTAL
Case Number
CC-DR-031 (Rev. 08/2024)
Page 3 of 7
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Case Number
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G. TRANSPORTATION EXPENSE
Automobile Payment
Automobile Repairs
Maintenance/Tags/Tires/etc.
Oil/Gas
Automobile Insurance
Parking Fees
Bus/Taxi
Other:
SUB TOTAL
H. GIFTS
Holiday Gifts
Birthdays
Gifts to Others
Charities
SUB TOTAL
I. CLOTHING
Purchasing
Laundry
Alterations/Dry Cleaning
Other:
SUB TOTAL
J. INCIDENTALS
Books & Magazines
Newspapers
Stamps/Stationery
Banking Expense
Other:
SUB TOTAL
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K. MISCELLANEOUS/OTHER
Alimony/Child Support (from a previous Order)
Religious Contributions
Hairdresser/Haircuts
Manicure/Pedicure
Pets/Boarding
Life Insurance
Other:
SUB TOTAL
TOTAL MONTHLY EXPENSES:
Number of dependent children, including children who have not attained the age of 19 years, are not
married or self-supporting, and are enrolled in secondary school:
INCOME STATEMENT
GROSS MONTHLY WAGES:
Deductions:
Federal
State
Medicare
F.I.C.A.
Retirement
Total Deductions:
NET INCOME FROM WAGES:
OTHER GROSS INCOME:
(alimony, part-time job, rentals etc.)
Deductions:
a.
b.
c.
Total deductions from Other income:
NET OTHER INCOME
TOTAL MONTHLY INCOME
CC-DR-031 (Rev. 08/2024) Page 5 of 7 FISTA
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ASSETS & LIABILITIES
ASSETS:
Real Estate
Furniture (in the marital house)
Bank Accounts/Savings
U.S. Bonds
Stocks/Investments
Personal Property
Jewelry
Automobiles
Boats
Other:
TOTAL ASSETS:
LIABILITIES:
Mortgage
Automobiles
Notes payable to relatives
Bank Loans
Accrued Taxes
Balance of Credit Card Accounts
a.
b.
c.
Other:
TOTAL LIABILITIES
TOTAL NET WORTH:
SUMMARY:
TOTAL INCOME:
TOTAL EXPENSES:
EXCESS OR DEFICIT:
CC-DR-031 (Rev. 08/2024) Page 6 of 7 FISTA
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I solemnly affirm under the penalties of perjury that the contents of this document, monthly expense list,
income statement, and assets and liabilities statement are true to the best of my knowledge, information, and
belief.
NOTE: If you are not filing this statement with a pleading or your response to the other party’s claim,
mail (postage prepaid) or hand deliver this statement to the other party and file a Certificate of Service
(CC-DR-058) with the court.
CC-DR-031 (Rev. 08/2024) Page 7 of 7 FISTA
Date
Signature
Printed Name
Street Address
City, State, Zip
Telephone Number
E-mail
Fax
Reset
