City/County
Court Address
Street Address
City, State, Zip
City, State, Zip
Street Address
Telephone
Telephone
Plaintiff
Defendant
CIRCUIT COURT FOR , MARYLAND
Located at Telephone
Case No.
vs.
FINANCIAL STATEMENT
(Child Support Guidelines)
(Md. Rule 9-203(b))
You must file a Notice Regarding Restricted Information Pursuant to Rule 20-201.1 (form MDJ-008)
with this submission.
I, , state that:
I am the of the minor child(ren),
including children who have not attained the age of 19 years old, are not married or self-supporting, and are
enrolled in secondary school:
The following is a list of my income and expenses (see below*):
See definitions on page 2 before filling out.
Total monthly income (before taxes)
Child support I am paying for my other child(ren) each month
Alimony I am paying each month to
Alimony I am receiving each month from
For the child or children listed above:
The monthly health insurance premium
Work-related monthly child care expenses
Extraordinary monthly medical expenses
School and transportation expenses
*To figure the monthly amount of expenses, weekly expenses should be multiplied by 4.3 and yearly expenses should be
divided by 12. If you do not pay the same amount each month for any of the categories listed, figure what your average
monthly expense is.
I solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my
knowledge, information, and belief.
CC-DR-030 (Rev. 08/2024) Page 1 of 2 FISTA
State relationship (for example, mother, father, aunt, grandfather, guardian, etc.)
Date
Signature
Name of Person(s)
Name of Person(s)
Name
$
$
$
$
$
$
$
$
This form contains Restricted Information.
Name
Date of Birth
Name
Name
Name
Name
Name
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Reset
Total Monthly Income: Include income from all sources including, self-employment, rent, royalties, business
income, salaries, wages, commissions, bonuses, dividends, pensions, interest, trusts, annuities, social security
benefits, workers compensation, unemployment benefits, disability benefits, alimony or maintenance received,
tips, income from side jobs, severance pay, capital gains, gifts, prizes, lottery winnings, etc. Do not report
benefits from means-tested public assistance programs such as food stamps or AFDC.
Extraordinary Medical Expenses: Uninsured expenses in excess of $250 in a calendar year for medical
treatment, including orthodontia, dental treatment, vision care, asthma treatment, physical therapy, treatment
for any chronic health problems, and professional counseling or psychiatric therapy for diagnosed mental
disorders.
Child Care Expenses: Actual child care expenses incurred on behalf of a child due to employment or job
search of either parent with amount to be determined by actual experience or the level required to provide
quality care from a licensed source.
School and Transportation Expenses: Any expenses for attending a special or private elementary or
secondary school to meet the particular needs of the child and expenses for transportation of the child between
the homes of the parents.
CC-DR-030 (Rev. 08/2024) Page 2 of 2 FISTA
