THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) FINANCIAL AFFIDAVIT OF ASSETS AND LIABILITIES IMPORTANT: You must also complete the Request for State of New Hampshire to pay Court Appointed Counsel and /or Guardian Ad Litem (NHJB-2609-P) and file it with this form. 1. 2. 3. Applicant Name: Name of Person Completing Form: List the names, ages, and relationship of dependents you support. 4. 5. 6. 7. 8. 9. If you are presently employed, state where and for how long. Full-Time If unemployed, state last date of employment. When do you anticipate new employment? If your spouse is presently employed, state where and for how long. Full-Time Part-Time If your spouse is unemployed, state last date of employment. List all other household members, their monthly income and their contributions to the household expenses if any. Part-Time 10. List any real estate you own, its market value and the amount you owe. Location: Market Value $ Mortgage Owed $ Net Value of Real Estate (Market Value minus Mortgage Owed) $ 11. List any vehicles you own (car, truck, motorcycle, snowmobile, recreation vehicle), their market value and the amount you owe: Description Market Amount Net Value Value Owed (Market Value minus Amt Owed)) NHJB-2017-P (07/30/2009) (Formerly AOC ­202A ­003) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT OF ASSETS & LIABILITIES 12. What money is presently available to you? Cash on hand ..................................................................................... Checking account ............................................................................... Savings account ................................................................................. Stocks/Bonds/IRA/Pension ................................................................. Total 13. Please state monthly take-home amount Salary/Wages Pension/Trust Benefits Unemployment Compensation Social Security Investment income Alimony Child Support Welfare Payments Other Total $ $ $ $ $ $ $ $ $ $ Applicant (You) (A) $ $ $ $ $ Spouse (B) $ $ $ $ $ $ $ $ $ $ 14. Please state your monthly household expenses: Rent/Mortgage $ Property Taxes $ Heat $ Food $ Utilities $ Medical/Dental $ Insurance $ Other $ Please specify Total $ 15. List income tax paid last year: Federal State 16. List income tax refund received last year: Federal State 17. Other than monthly household expenses, list any bills you owe, amount owed, to whom, and monthly payment: 18. List which of your bills are court-ordered payments (i.e. alimony, judgment in a law suit, etc.): NHJB-2017-P (07/30/2009) (Formerly AOC ­202A ­003) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: FINANCIAL AFFIDAVIT OF ASSETS & LIABILITIES 19. Other than those previously mentioned, list anyone to whom you owe money, amount and when it is due: 20. If anyone owes you money, state name, address, amount due, and when due: 21. List any property you have transferred within the last three years, to whom and for what price: 22. List any other assets, income or expenses not previously mentioned: I swear or affirm the foregoing information is true and correct to the best of my knowledge under penalties of law. Date Signature of applicant or person completing form State of This instrument was acknowledged before me on , County of by Date Person Signing above My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title NHJB-2017-P (07/30/2009) (Formerly AOC ­202A ­003) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com