Miss. Ch. C. R., [Effective 4/18/2024] Administrative orders, exh. A

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As amended through October 22, 2024

Exhibit A - [Effective 4/18/2024]

IN THE CHANCERY COURT OF _______________________COUNTY

STATE OF MISSISSIPPI

__________________________

PLAINTIFF

VS.

__________________________

CIVIL ACTION NUMBER

__________________________

DEFENDANT

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I. GENERAL INFORMATION

NAME: _______________________________________________________________

ADDRESS: ___________________________________________________________

CITY, STATE AND ZIP CODE: _____________________________________________

DATE OF BIRTH: ______________________________________________________

SOCIAL SECURITY NUMBER: ____________________________________________

OCCUPATION: ________________________________________________________

EMPLOYER: __________________________________________________________

EMPLOYER'S ADDRESS: ________________________________________________

_____________________________________________________________________

	NAME	DATE OF BIRTH
MINOR CHILDREN:	__________________________________________________________
	__________________________________________________________
	__________________________________________________________

________________________________________________________________________

II. INCOME STATEMENT
GROSS MONTHLY INCOME
1.	Salary and Wages, including commissions bonuses, allowance and overtime	1.	________________
	NOTE: ^{To arrive at a monthly income figure, if paid weekly, multiply weekly income by 4.3; if paid bi-weekly, multiply bi-weekly income by 2.16}
2.	Pensions and retirement	2.	________________
3.	Social Security	3.	________________
4.	Disability and unemployment insurance	4.	________________
5.	Public assistance (welfare, AFDC payments, etc.)	5.	________________
6.	Dividends and interest	6.	________________
7.	Rental Income	7.	________________
8.	Other income ____________________________________________________	8.	________________
9.	Other income ____________________________________________________	9.	________________
10.	TOTAL MONTHLY INCOME	10.	________________
ITEMIZED MONTHLY DEDUCTIONS:
1.	State Income Taxes	1.	________________
2.	Federal Income Taxes	2.	________________
3.	Social Security	3.	________________
4.	Mandatory Insurance	4.	________________
5.	Mandatory Retirement	5.	________________
6.	Union or other dues	6.	________________
7.	Other: (Specify) ___________________________________________________	7.	________________
8.	Other: (Specify) ___________________________________________________	8.	________________
9.	TOTAL MONTHLY DEDUCTIONS	9.	________________
10.	NUMBER OF EXEMPTIONS: ____________________
11.	NET MONTHLY PAY	11.	________________
III. EXPENSE STATEMENT

A. LIVING EXPENSES	AS OF ____________		AS OF ____________
	Self	Children	Self	Children
1. Rent/Mortgage (Residence)
2. Real Property Taxes
3. Real Property Insurance
4. Maintenance (Residence)
5. Food/Household Supplies
6. Water, Sewer, etc.
7. Electricity
8. Gas (Residence)
9. Telephone
10. Laundry & Cleaning
11. Clothing
12. Insurance (Not payroll deducted)
13. Medical
14. Dental
15. Child Care
16. Children's Allowance
17. Payment of child support/alimony (^{Prior Marriage})
18. School Expenses
19. Entertainment
20. Incidentals & Miscellaneous
21. Transportation other than vehicle
22. Gasoline & Oil (auto)
23. Repair (auto)
24. Insurance (auto)
25. Auto payments
26. Church donations
27. Charitable donations
28. Newspaper/Magazines
29. Cable TV
30. Pet Expenses
31. Yard Expenses
32. Maid
33. Retirement (IRA, etc.)
34. Pest Control
B. TOTAL LIVING EXPENSES
35. Installment Payments ^{Notes, loans, charge accounts, etc.}
36 .
37.
38.
39. OTHER EXPENSES
40.
41.
TOTAL INSTALLMENT PAYMENTS:
COMBINED TOTAL EXPENSES:

IV.	STATEMENT OF ASSETS
A.	Real Estate
	1.	Title in the name of :	_________________________________________________________
		Address:	_________________________________________________________
		Who paid cost:	_________________________________________________________
		How cost paid:	_________________________________________________________
		Value (estimate)	_________________________________________________________
		Mortgage Balance	_________________________________________________________
		Equity	_________________________________________________________
	2.	Title in the name of :	_________________________________________________________
		Address:	_________________________________________________________
		Who paid cost:	_________________________________________________________
		How cost paid:	_________________________________________________________
		Value (estimate)	_________________________________________________________
		Mortgage Balance	_________________________________________________________
		Equity	_________________________________________________________

	Note: List mortgage balance also under liabilities on the next page. List the amount of your monthly payment only under "V. LIABILITIES."
B.	Motor Vehicles
	1.	Registered in the name of: __________________________________________
		Year: _______________ Model: ______________________ Mileage: _____________________
		How cost paid: ___________________ How cost paid: ___________________
			VALUE
			- Loan Balance _________________________
			=Equity _______________________________
	2.	Registered in the name of:
		Year: _______________ Model: ______________________ Mileage: _____________________
		How cost paid: ___________________ How cost paid: ___________________
			VALUE
			- Loan Balance _________________________
			=Equity _______________________________
	3	Registered in the name of:
		Year: _______________ Model: ______________________ Mileage: _____________________
		How cost paid: ___________________ How cost paid: ___________________
			VALUE
			- Loan Balance _________________________
			=Equity _______________________________
C.	Other Personal Property		(such as home computers, guns, lawnmowers, TVs, jewelry, household furnishings, etc.)

	VALUES
____________________________________________	____________________________________________
____________________________________________	____________________________________________
____________________________________________	____________________________________________
____________________________________________	____________________________________________
____________________________________________	____________________________________________
TOTAL	____________________________________________

D. Checking/Savings (name of Bank, Account Number and Amount in Account, including CDs, money markets, passbook accounts, etc.)
Name(s) on Account	Bank/Account Number	Type Account	Balance
_____________________	__________________	______________	______________
_____________________	__________________	______________	______________
_____________________	__________________	______________	______________
_____________________	__________________	______________	______________
TOTAL VALUE			______________

E. Other Investments (IRAs, stock(s), mutual funds, pension plans, etc.)
Bank/Account Number	Type Investment	Balance
_____________________________	___________________	______________
_____________________________	___________________	______________
_____________________________	___________________	______________
_____________________________	___________________	______________
_____________________________	___________________	______________

F. Life Insurance (exclude children)
Insured	Company	Face Amount	Cash	Beneficiary
______________	______________	______________	______________	______________
______________	______________	______________	______________	______________
______________	______________	______________	______________	______________
TOTAL CASH VALUE (less loans)			______________

G. All Other Assets
__________________________________________		__________________________________________
__________________________________________		__________________________________________
__________________________________________		__________________________________________
TOTAL VALUE		__________________________________________
TOTAL OF ALL ASSETS	$	__________________________________________

V. STATEMENT OF LIABILITIES
(Include mortgage, car loan, credit cards, personal loans) Note: Also include under items 35-44 on Exhibit "A"
	A. Creditor	Party Responsible	Current	Monthly	Who Makes
		for Payment	Balance	Payment	Payments
1.	__________________	__________________	_____________	_____________	_____________
2.	__________________	__________________	_____________	_____________	_____________
3.	__________________	__________________	_____________	_____________	_____________
4.	__________________	__________________	_____________	_____________	_____________
5.	__________________	__________________	_____________	_____________	_____________
6.	__________________	__________________	_____________	_____________	_____________

	B. TOTAL LIABILITIES		_________________________

ACKNOWLEDGMENT OF TRUTHFULNESS

I declare to the Court that the foregoing Exhibit "A" including attachments, is true and correct and that this declaration was executed on the ______ day of ____________, 20___.

___________________________________

Party's Signature

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IN THE CHANCERY COURT OF ____________________ COUNTY

STATE OF MISSISSIPPI

_______________________________________
PLAINTIFF

	_______________________________________
	CIVIL ACTION NUMBER

_______________________________________
DEFENDANT

CERTIFICATE OF COMPLIANCE

I,____ (name of party or attorney) ____, do hereby certify that I have this date complied with Rule 8.05 of the Uniform Chancery Court Rules and that I have mailed and/or delivered a copy of a detailed written statement of actual income and expenses and assets and liabilities to the attorney for the opposing party or the opposing party.

SO CERTIFIED on this the _____ day of _______________, 20____.

___________________________________

Attorney Or Opposing Party

Miss. Ch. C. R., [Effective 4/18/2024] Administrative orders, exh. A