FINANCIAL AFFIDAVIT
State of
______________________)
County of _______________________) On ______________________________, before me, ________________________ personally appeared _____________________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument and was sworn and says that the following statement of affiant’s income, assets and liabilities is true: Occupation: ___________________________________________________________________ Employed By: _________________________________________________________________ Business Address: ______________________________________________________________ Pay Period: ____________________________________________________________________ Rate of Pay: _________________________________________ Social Security Number: _______________________________ ITEM 1: INCOME (Averaged on _____________ basis): Average $_____________________ Less Deductions Federal Income Tax $_________________ Social Security $_________________ Other $__________________ Total Deductions $ __________________ $ _____________________ $ _____________________ $______________________ TOTAL NET INCOME $ _____________________ GROSS Wage
ip: If joint, allocate equally): Cash on hand or in banks Stocks, bonds, notes Real estate Home Other Automobiles Other personal property Other assets _________________________ TOTAL ASSETS
$ _____________________ $ _____________________ $ ______________________ $ ______________________ $ ______________________ $ ______________________ $ ______________________ $ ______________________
$_______________ $_______________ $_______________ $_______________ $_______________ TOTAL LIABILITIES
Balance Due $_______________ $_______________ $_______________ $_______________ $_______________
Monthly Payments
$ _______________
THLY EXPENSES Household: Mortgage or rent payments Food and grocery items Utilities Automobile: Gasoline and oil Repairs Insurance Children’s Expenses: Clothing Medical, dental, prescriptions Daycare/School School supplies Other expenses TOTAL AVERAGE MONTHLY EXPENSES
$ ________________ $ ________________ $ ________________ $ ________________ $_________________ $ ________________ $ ________________ $ ________________ $ ________________ $________________ $ ________________ $_________________
STATE OF _____________________)
_______)
s acknowledged before me this ___ day of________, 200__ _______ [ ] who is personally known to me [ ] or has produced __________________ as identification.
___________ Print Name:___________________ Title: Notary Public Serial No. (if any)___________
IF A NONLAWYER ASSISTED YOU FILL OUT THIS FORM, THEY MUST FILL IN ALL THE BLANKS BELOW:
_________________________, am a nonlawyer residing at (street) _______________________, (city) _____________________, (state) _____, (phone) _______ helped (name of spouse) ____________________, who is the _____ petitioner or _____ respondent, fill out this document.