Income Survey - Mountain Mediation Center

Domestic Mediation Questionnaire

Mountain Mediation Center – Income Survey

We offer our services on a sliding scale, based on federal poverty guidelines. Please complete this form if you are interested in receiving a reduced or waived fee.

Income Survey

Fees for mediation are split evenly between the parties, unless you have made a mutual decision together to alter this arrangement. If you believe mediation will be of assistance to you but don’t feel you can afford the process, we offer our services on a sliding scale based on federal poverty guidelines. Please submit the forms below and remit the $25 administrative fee.

1. HOUSEHOLD INFORMATION

Beginning with yourself, list all people living with you for whom you are responsible or with whom you share food and household expenses regardless of age or relationship to you. Include the gross income* of every person over 18 years of age with whom you share household expenses.

Full Name

First Name, Last Name

Date of Birth:

Relationship to You:

Husband, daughter, etc...

Gross Monthly Salary: $

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Full Name

First Name, Last Name

Date of Birth:

Relationship to You:

Husband, daughter, etc...

Gross Monthly Salary: $

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Full Name

First Name, Last Name

Date of Birth:

Relationship to You:

Husband, daughter, etc...

Gross Monthly Salary: $

----------------------------------------------------------------------------------------------------------------------------------

Full Name

First Name, Last Name

Date of Birth:

Relationship to You:

Husband, daughter, etc...

Gross Monthly Salary: $

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Full Name

First Name, Last Name

Date of Birth:

Relationship to You:

Husband, daughter, etc...

Gross Monthly Salary: $

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2. Financial Information

A. Employment

Employer:

Starting Date:

Phone Number

Hourly Wages: $

Hours/Weeks:

Type of Work:

Gross Monthly Income: $

B. Other Income
(Enter amounts for applicable options)

Alimony: $

Child Support: $

Disability Benefits: $

Rental Income: $

Social Security: $

Unemployment Comp: $

Retirement/Pension: $

C. Deductions

Alimony: $

Child Support: $

STATEMENT OF VERIFICATION

I verify, under penalties of perjury, that the information given above is true and correct and that, if any of this information changes after submitting this form, I will inform Mountain Mediation Center.

Signature

Clear

Printed Name

Today's Date

Domestic Mediation Questionnaire

Mountain Mediation Center – Income Survey

1. HOUSEHOLD INFORMATION

2. Financial Information

A. Employment

B. Other Income
(Enter amounts for applicable options)

C. Deductions

STATEMENT OF VERIFICATION

Mailing List

Join Today

Domestic Mediation Questionnaire

Mountain Mediation Center – Income Survey

1. HOUSEHOLD INFORMATION

2. Financial Information

A. Employment

B. Other Income (Enter amounts for applicable options)

C. Deductions

STATEMENT OF VERIFICATION

Mailing List

Join Today

B. Other Income
(Enter amounts for applicable options)