family law financial affidavit - Eighteenth Judicial Circuit Court

IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL
CIRCUIT, IN AND FOR
COUNTY, FLORIDA
Case No.:
Division:
,
Petitioner,
and
,
Respondent.
FAMILY LAW FINANCIAL AFFIDAVIT (SHORT FORM)
(Under $50,000 Individual Gross Annual Income)
I, {full legal name}
following information is true:
My Occupation:
, being sworn, certify that the
Employed by:
Business Address:
Pay rate: $
every week ( ) every other week ( ) twice a month ( ) monthly (
o Check here if unemployed and explain on a separate sheet your efforts to find employment.
) other:
I have filed or am filing a completed Notice of Social Security Number form with this affidavit.
SECTION I. PRESENT MONTHLY GROSS INCOME:
All amounts must be MONTHLY. Attach more paper, if needed. Items included under “other” should be listed separately
with separate dollar amounts.
1. Monthly gross salary or wages
2. Monthly bonuses, commissions, allowances, overtime, tips, and similar
payments
3. Monthly business income from sources such as self-employment,
partnerships, close corporations, and/or independent contracts (gross receipts
minus ordinary and necessary expenses required to produce income) (o
Attach sheet itemizing such income and expenses.)
4. Monthly disability benefits/SSI
5. Monthly Workers' Compensation
6. Monthly Unemployment Compensation
7. Monthly pension, retirement, or annuity payments
8. Monthly Social Security benefits
9. Monthly alimony actually received
9a. From this case:
$ _____________
9b. From other case(s):
_____________
Add 9a and 9b
10. Monthly interest and dividends
11. Monthly rental income (gross receipts minus ordinary and necessary expenses
required to produce income) (o Attach sheet itemizing such income and
expense items.)
12. Monthly income from royalties, trusts, or estates
13. Monthly reimbursed expenses and in-kind payments to the extent that they
reduce personal living expenses
14. Monthly gains derived from dealing in property (not including nonrecurring
gains)
Any other income of a recurring nature (list source)
15.
16.
17. PRESENT MONTHLY GROSS INCOME (Add lines 1-16)
TOTAL:
1.
2.
$
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17. $
PRESENT MONTHLY DEDUCTIONS:
18. Monthly federal, state, and local income tax (corrected for filing status and
allowable dependents and income tax liabilities)
a. Filing Status ______________________
b. Number of dependents claimed _______
19. Monthly FICA or self-employment taxes
20. Monthly Medicare payments
21. Monthly mandatory union dues
22. Monthly mandatory retirement payments
23. Monthly health insurance payments (including dental insurance), excluding
portion paid for any minor children of this relationship
24. Monthly court-ordered child support actually paid for children from another
relationship
25. Monthly court-ordered alimony actually paid
25a. from this case:
$ _____________
25b. from other case(s):
_____________ Add 25a and 25b
26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30,
FLORIDA STATUTES
(Add lines 18 through 25)
PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)
A. HOUSEHOLD:
Mortgage or rent
Property taxes
Utilities
Telephone
Food
Meals outside home
Maintenance/Repairs
Other:
$
$
$
$
$
$
$
$
B. AUTOMOBILE
Gasoline
Repairs
Insurance
$
$
$
C. CHILD(REN)’S EXPENSES
Day care
Lunch money
Clothing
Grooming
Gifts for holidays
Medical/dental (uninsured)
Other:
$
$
$
$
$
$
$
D. INSURANCE
Medical/dental
Child(ren)’s medical/dental
Life
Other:
$
$
$
$ ____________
TOTAL:
18. $
19.
20.
21.
22.
23.
24.
25.
26. $
27. $
E. OTHER EXPENSES NOT LISTED ABOVE
Clothing
$
Medical/Dental (uninsured)
$
Grooming
$
Entertainment
$
Gifts
$
Church/Charities
$
Miscellaneous
$
Other:
$
$
$
$
$
$
$
F. PAYMENTS TO CREDITORS
CREDITOR:
_______________________
MONTHLY
PAYMENT
$
$
$
$
$
$
$
$
$
$_____________
$_____________
28. TOTAL MONTHLY EXPENSES (add ALL monthly amounts in A through F above)
SUMMARY
29. TOTAL PRESENT MONTHLY NET INCOME (from line 17 of SECTION
I. INCOME)
30. TOTAL MONTHLY EXPENSES (from line 28 above)
31. SURPLUS (If line 29 is more than line 30, subtract line 30 from line 29.
This is the amount of your surplus. Enter that amount here.)
32. (DEFICIT) (If line 30 is more than line 29, subtract line 29 from line 30.
This is the amount of your deficit. Enter that amount here.)
$ ____________
29. $
30. $
31. $
32. ($
)
SECTION III: ASSETS AND LIABILITIES
Use the nonmarital column only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,”
meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item(s) or
debt belongs. (Typically, you will only use this column if property/debt was owned/owed by one spouse before the marriage.)
A. ASSETS:
DESCRIPTION OF ITEM(S). List a description of each separate item owned by
you (and/or your spouse, if this is a petition for dissolution of marriage).
√ the box next to any asset(s) which you are requesting the judge award to you.
o Cash (on hand)
Current Fair
Market Value
Nonmarital
(√
√ correct column)
husband
Wife
$
o Cash (in banks or credit unions)
o Stocks, Bonds, Notes
o Real estate: (Home)
o (Other)
o Automobiles
o Other personal property
o Retirement plans (Profit Sharing, Pension, IRA , 401(k)s, etc.)
o Other
o
o
o
o
o
o
o √ here if additional pages are attached.
Total Assets (add column B)
$
B. LIABILITIES:
DESCRIPTION OF ITEM(S). List a description of each separate debt owed by
you (and/or your spouse, if this is a petition for dissolution of marriage).
√ the box next to any debt(s) for which you believe you should be responsible.
o Mortgages on real estate
Current
Amount Owed
Nonmarital
(√
√ correct column)
husband
$
Wife
DESCRIPTION OF ITEM(S). List a description of each separate debt owed by
you (and/or your spouse, if this is a petition for dissolution of marriage).
√ the box next to any debt(s) for which you believe you should be responsible.
Current
Amount Owed
Nonmarital
(√
√ correct column)
husband
Wife
o Auto loans
o
o Charge/credit card accounts
o
o
o
o Other
o
o
o
o
o
o
o √ here if additional pages are attached.
Total Debts (add column B)
$
C. CONTINGENT ASSETS AND LIABILITIES
INSTRUCTIONS: If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.)
or POSSIBLE liabilities (possible lawsuits, future unpaid taxes, debts assumed by another), you must list them here.
Contingent Assets
Nonmarital
Possible Value
√ the box next to any contingent asset(s) which you are requesting the judge award to you.
o
(√
√ correct column)
husband
Wife
$
o
$
Total Contingent Assets
Contingent Liabilities
√ the box next to any contingent debt(s) for which you believe you should be responsible.
o
Possible Amount
Owed
Nonmarital
(√
√ correct column)
husband
Wife
$
o
Total Contingent Liabilities
$
SECTION IV: CHILD SUPPORT GUIDELINES WORKSHEET
(_rChild Support Guidelines Worksheet, MUST be filed in all cases in which the parties have a minor child in
common, INCLUDING modifications of child support.)
[√ one only]
___
A Child Support Guidelines Worksheet IS being filed in this case. The parties have one or
more minor children in common or one of the parties is requesting a modification of a previous
court order regarding child support.
___
A Child Support Guidelines Worksheet IS NOT being filed in this case. There are no minor
children common to the parties in this case or, if this case involves a modification of a previous
court order, child support is not an issue.
I certify that a copy of this document was [√ one only] ( ) mailed ( ) faxed and mailed (
hand delivered to the person(s) listed below on {date} _______________________, 199___.
)
Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:
I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this affidavit and that the punishment for knowingly making a false statement includes
fines and/or imprisonment.
Dated:
Signature of Party
Printed Name:
Address:
City, State, Zip:
Telephone Number:
Fax Number:
STATE OF FLORIDA
COUNTY OF
)
)
Sworn to or affirmed and signed before me on _______________________________, _____ by
________________________________.
NOTARY PUBLIC—STATE OF FLORIDA
[Print, type, or stamp commissioned name of notary.]
Personally known
Produced identification
Type of identification produced ___________________________________
IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE
BLANKS BELOW: [ ? fill in all blanks]
I, {full legal name and trade name of nonlawyer}
,
a nonlawyer, located at {street}
, {city}
,
{state}
, {phone}
, helped {name}
,
who is the [ √ one only]
petitioner or
respondent, fill out this form.