Comes now the Defendant(s) and, subject to the penalty of perjury, makes oath and says that the following facts are true and that there is NO OTHER source of income or property other than that described below:

1. Full name:						
Address: 			 			
Phone #  						
Soc. Sec. No. 						 
Employer: 						
Phone # 							

2.   List all dependents:
Name			Age		Relationship

										

3.   List all income from any source:   
$ 			 	per/wk  /mo  ,
from 										:
$ 			 	per/wk  /mo  ,
from 										:
$ 			 	per/wk  /mo  ,
from 										:

I receive CHILD SUPPORT in the sum of 
$ 			  per 							.

4.   List all bank accounts:
ACCOUNT   	BANK/SOURCE      		BALANCE
Checking				$ 								
Savings  				$ 				 				
Other:   				  	$ 							
Other:       				$ 								

5.   List all debts:
CREDITOR/ADDRESS              	BALANCE
					  	$ 			
						$ 			
						$ 			
						$ 			
					 	$ 			

6.   List all monthly household expenses:
Rent/Mortgage:    				$ 		
Utilities:         	 			$ 		
Health Insurance:  				$ 		
Transportation Cost:				$ 		
Food:             				$ 		
Clothing:          				$ 		
Other:             				$ 		
					$ 			
					$ 			
					$ 			

	TOTAL				$ 					

7.   List all land/house/real estate/property you own:
DESCRIBE                  				VALUE
				  		$ 		
						$ 		
				 		$ 		
				 		$ 		
8.   List all personal property/cars/trucks/ furniture/stocks/bonds/tools/equipment you own and its total value:
DESCRIBE                   				VALUE
Cars 					$ 	
Trucks 					$  	
Other 					$  	
					$  	
					$  	
					$  	

9.   List all assets/property sold or transferred in the last six months:
DESCRIBE                    				VALUE
				 	$ 	 	
					$ 		
					$ 		
				 	$ 		
					$ 		

10.  The last income tax I filed was for 	 and it reflected an income of $ 		 and I attach a copy hereto or will file the same within seven days.

LIST ALL PROPERTY YOU CLAIM TO BE EXEMPT PURSUANT TO LAW:
All clothing for myself and my family; all receptacles for said clothing; family portraits; family Bible; school books; and 

																

VERIFICATION AND OATH:  Comes now the Petitioner(s) / Defendant(s) and makes oath, subject to the penalty of perjury, that the information in this Motion for Installment Payment is true to the best of Petitioner's knowledge, information and belief.
Defendant(s) 							 							

Sworn to and subscribed before me 
on ____________________
						
Clerk/Deputy Clerk/Notary Public

Commission Expires: