Name: Mailing Address: City, State, Zip Code: Daytime Phone Number: Evening Phone Number: Representing: State Bar Number: [ ] Self [ ] Petitioner [ ] Respondent ARIZONA SUPERIOR COURT, COUNTY OF YAVAPAI Case No. Petitioner ATLAS No. ___________________________________ Respondent AFFIDAVIT OF FINANCIAL INFORMATION Affidavit of (Name of Person Whose Information is on this Affidavit) IMPORTANT INFORMATION ABOUT THIS DOCUMENT WARNING TO PARTIES: This Affidavit is an important document. You must fill out this Affidavit completely, and provide accurate information. You must provide copies of this Affidavit and all other required documents to the other party and to the judge. I have read the following document and know of my own knowledge that the facts and financial information stated below are true and correct, and that any false information may constitute perjury by me. I also understand that, if I fail to provide the required information or give misinformation, the judge may order sanctions against me, including assessment of fees under Rule 31. ____________________________________ Signature of Person Making Affidavit Date Superior Court of Arizona in Yavapai County Jan 2009 Page 1 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ INSTRUCTIONS 1. Complete the entire Affidavit in black ink. If the spaces provided on this form are inadequate, use separate sheets of paper to complete the answers and attach them to the Affidavit. Answer every question completely! You must complete every blank. If you do not know the answer to a question or are guessing, please state that. If a question does not apply, write “NA” for “not applicable” to indicate you read the question. Round all amounts of money to the nearest dollar. 2. You must provide the other party with copies of the following: A. Proof of your year to date income from all sources, including your two most recent pay stubs. B. Complete copies of your federal income tax returns for the last three years with all schedules and attachments. C. All W-2 and 1099 forms from all sources of income for the last three years. D. If self-employed, a member of a partnership, or a shareholder of a closely held corporation, complete copies of the business federal income tax returns for the last three years with all schedules and attachments. [ ] YES [ ] NO I have provided the other party with copies of the documents described above. If no, explain your answer. [ ] YES [ ] NO [ ] YES [ ] NO 1. 2. I attached copies of my two (2) most recent pay stubs. 3. I attached copies of my federal income tax return for the last three (3) years, and I attached my W-2 and 1099 forms from all sources of income. GENERAL INFORMATION: A. Name: Date of Birth: B. Current Address: C. Date of Marriage: Date of Divorce: D. Last date when you and the other party lived together: E. Full name(s) of child(ren) common to the parties (in this case date(s) of birth, and Social Security Number(s) (last 4 digits only): Name Date of Birth Last Four Digits of Social Security Number Superior Court of Arizona in Yavapai County Jan 2009 Page 2 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ F. The name, date of birth, relationship to you, and gross monthly income for each individual who lives in your household: Name Date of Birth Relationship to you Income G. Any other person for whom you contribute support: Name Age Relationship Reside With Court Order to to You You (Y/N) Support (Y/N) H. Attorney’s Fees paid in this matter $ 2. . Source of funds EMPLOYMENT INFORMATION: A. Your job/occupation/profession/title: Name and address of current employer: Date employment began: How often are you paid: [ ] Weekly [ ] Every other week [ ] Monthly [ ] Twice a month [ ] Other B. If you are not working, why not? C. Previous employer name and address: Previous job/occupation/profession/title: Date previous job began: Date previous job ended: Reason you left job: Gross monthly pay at previous job: $ D. Total gross income from last three (3) years’ tax returns. Year 20 $ Year 20 $ Year 20 $ E. Your total gross income from January 1 of this year to the date of this Affidavit (year-to-date income): $ 3. YOUR EDUCATION/TRAINING: List name of school, length of time there, year of last attendance, and degree earned: A. High School: B. College: C. Post-Graduate: D. Occupational Training: 4. YOUR GROSS MONTHLY INCOME: • List all income you receive from any source, whether private or governmental, taxable or not. • List all income payable to you individually and all non-wage income payable jointly to you and your spouse. • Use a monthly average for items that vary from month to month. Superior Court of Arizona in Yavapai County Jan 2009 Page 3 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ • Multiply weekly income by 4.33. Multiply biweekly income by 2.165 to arrive at the monthly total. A. Gross salary/wages per month $ • Attach copies of your two most recent pay stubs. Rate of pay $ per [ ] hour [ ] week [ ] month [ ] year B. Expenses paid for by your employer: 1. Automobile provision or allowance 2. Auto expenses, such as gas, repairs, insurance 3. Lodging 4. Other (explain) C. Commissions/ bonuses D. Tips E. Self-employment income (see below) F. Social Security benefits G. Worker's compensation and/or disability income H. Unemployment compensation I. Gifts/ prizes J. Payments from prior spouse K. Rental income (net after expenses) L. Contributions to household living expense by others M. Other (explain) : (Include dividends, pensions, interest, trust income, annuities or royalties.) TOTAL: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 5. SELF-EMPLOYMENT INCOME (if applicable): If you are self-employed, a member of a partnership, or a shareholder of a closely held corporation, provide the following information: Name, address and telephone no. of business: Type of business entity: State and date of incorporation/formation: Nature of your interest: Nature of business: Percent ownership: Number of shares of stock: Total issued and outstanding shares: Gross sales/revenue last 12 months: Superior Court of Arizona in Yavapai County Jan 2009 Page 4 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ INSTRUCTIONS Both parties must answer item 6 if either party asks for child support. These expenses include only those expenses for children who are common to the parties, which means one party is the birth/adoptive mother and the other is the birth/adoptive father of the children. 6. SCHEDULE OF ALL MONTHLY EXPENSES FOR CHILDREN: • DO NOT LIST any expenses for the other party, or child(ren) who live(s) with the other party, unless you are paying those expenses. • Use a monthly average for items that vary from month to month. • If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the estimated amount. A. HEALTH INSURANCE: Do you have health insurance available? Yes No Are you enrolled? Yes No Total monthly cost $ 2. Premium cost to insure you alone $ 3. Premium cost to insure child(ren) common to the parties $ 4. List all people covered by your insurance coverage: 5. Name of insurance company and policy/group number: B. DENTAL/VISION INSURANCE 1. Total monthly cost 2. Premium cost to insure you alone 3. Premium cost to insure child(ren) common to the parties 4. List all people covered by your insurance coverage: $ $ $ 5. Name of insurance company and policy/ group number: C. UNREIMBURSED MEDICAL AND DENTAL EXPENSES: (cost to you after, or in addition to, any insurance reimbursement) 1. Drugs and medical supplies 2. Other TOTAL: D. CHILD CARE COSTS: 1. Total monthly child care costs (do not include amounts paid by D.E.S.) 2. Name(s) of child(ren) cared for and amount per child: $ $ $ $ $ $ $ $ 3. Name(s) and address(es) of child care provider(s): Superior Court of Arizona in Yavapai County Jan 2009 Page 5 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ E. EMPLOYER PRETAX PROGRAM: Do you participate in an employer program for pretax payment of child care expenses (Cafeteria Plan)? [ ] YES [ ] NO F. COURT ORDERED CHILD SUPPORT: 1. Court ordered current child support for child(ren) not common to the parties $ 2. Amount of any arrears payment $ 3. Amount per month actually paid in last 12 months. $ • Attach proof that you are paying 4. Name(s) and relationship of minor child(ren) who you support or who live with you, but are not common to the parties: G. COURT ORDERED SPOUSAL MAINTENANCE/SUPPORT (Alimony): 1. Court ordered spousal maintenance/support you actually pay to previous spouse: $ H. EXTRAORDINARY EXPENSES: 1. For Children (educational special needs/other): Explain: 2. For Self: Explain: $ $ INSTRUCTIONS You must answer items 7 and 8 if either party is requesting: • Spousal maintenance • Division of expenses • Attorneys’ fees and costs • Adjustment or deviation from the child support amount • Enforcement of prior orders 7. • • • SCHEDULE OF ALL MONTHLY EXPENSES: Do NOT list any expenses for the other party, or children who live with the other party unless you are paying those expenses. Use a monthly average for items that vary from month to month. If you are listing anticipated expenses, indicate this by putting an asterisk (*) next to the estimated amount. A. HOUSING EXPENSES: 1. House payment: a. First mortgage b. Second mortgage Superior Court of Arizona in Yavapai County Jan 2009 $ $ Page 6 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ c. Homeowners’ association fee d. Rent 2. Repair & upkeep 3. Yard work/pool/pest control 4. Insurance & taxes not included in house payment 5. Other (explain) TOTAL: B. UTILITIES: 1. Water, sewer, and garbage 2. Electricity 3. Gas 4. Telephone 5. Mobile phone/pager 6. Internet provider 7. Cable/satellite television 8. Other (explain:) TOTAL: C. FOOD: 1. Food, milk, and household supplies 2. School lunches 3. Meals outside home TOTAL: D. CLOTHING: 1. Clothing for you 2. Uniforms or special work clothes 3. Clothing for children living with you 4. Laundry and dry-cleaning TOTAL: E. TRANSPORTATION OR AUTOMOBILE EXPENSES: 1. Car insurance 2. List all cars and individuals covered: 3. 4. 5. 6. 7. Car payment, if any Car repair and maintenance Gas and oil Bus fare/parking fees Other (explain): TOTAL: F. MISCELLANEOUS: 1. School tuition 2. School supplies 3. School activities or fees 4. Extracurricular activities of child(ren) 5. Church/contributions Superior Court of Arizona in Yavapai County Jan 2009 Page 7 of 8 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com Case No. ________________________ 6. Newspapers, magazines and books $ 7. Barber and beauty shop $ 8. Life insurance (beneficiary: ) $ 9. Disability insurance $ 10. Recreation/entertainment $ 11. Child(ren)'s allowance(s) $ 12. Union/professional dues $ 13. Voluntary retirement contributions and savings deductions $ 14. Family gifts $ 15. Pet expenses $ 16. Cigarettes $ 17. Alcohol $ 18. Other (explain): $ TOTAL: $ G. OTHER DEBTS: List all debts and installment payments you currently owe that are not listed above. Follow the format below. Use additional paper if necessary. Creditor Name Purpose of Debt Unpaid Balance Minimum Monthly Payment Date of Your Last Payment Amount of Last Monthly Payment TOTAL OF LAST MONTHLY PAYMENTS: $ 8. TOTAL OF ALL MONTHLY EXPENSES FROM ITEMS 6 & 7 ABOVE: $_________ Superior Court of Arizona in Yavapai County Jan 2009 Page 8 of 8 Aff.Fin.Info American LegalNet, Inc. www.FormsWorkflow.com