Name of Person Filing: Mailing Address: City, State, Zip: Phone Number: Representing Self SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO Petitioner's Name on the Petition that started this case: Case Number: DO AFFIDAVIT OF FINANCIAL INFORMATION Respondent's Name: I am the [ ] Petitioner or [ ] Respondent INSTRUCTIONS: DON'T LEAVE ANYTHING BLANK: If a question doesn't apply, write "NA" for "not applicable". If you don't know the answer or are guessing, say that. Round all amounts to the nearest dollar. If there's not enough room for your answers, attach more paper. After completing the form, file the following with the court: [] [] [] Affidavit of Financial Information Copies of your two most recent pay stubs If you're court-ordered to pay child support or arrears for children of other relationships: Proof of your payments over the last 12 months And give copies of the following to the other party: [] [] [] [] [] Affidavit of Financial Information and any attachments Proof of your year-to-date income from all sources, including your two most recent pay stubs Complete copies of your federal income tax returns for the last three years with all schedules and attachments Your W-2 and 1099 forms from all sources of income for the last three years If you are 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 Are you sending copies of the items listed above to the other party? [ ] Yes [ ] No. If No, why not? Page 1 of 10 Revised July 2013 © 2013 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com OATH: I've read this Affidavit. The facts and financial information in it are true and correct. I understand that it might be perjury if I list false information. I understand that if I leave anything blank or list wrong information, the judge might order sanctions against me, including fees and expenses under Rule 31, Arizona Rules of Family Law Procedure. Date: My Signature: GENERAL INFORMATION: Birthdate: My Name: Current Address: Last date that I and the other party lived together: For married or divorced parties: Date of Our Marriage: Our divorce is [ ] pending or [ ] final. If final: Date of Divorce: Children: These are all the children who are under 18 and are my and the other party's biological or adopted children: Name Birthdate Last 4 Digits of Social Security Number Household: These are all the people who live in my household: Relationship to Me Gross Monthly Income Name Birthdate Other People I Support: These are all other people who I support and who are not already listed above: Lives with Me? (Y/N) I'm CourtOrdered to Support Them? (Y/N) Name Relationship to Me Age Page 2 of 10 Revised July 2013 © 2013 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com Attorney's Fees: Attorney's fees I've paid in this case: $ Where I got the money to pay those fees: Employment: My job/occupation/profession/title: My current employer's name: Current employer's address: Date current employment began: How often I'm paid: [ ] Weekly [ ] Every other week [ ] Monthly [ ] Twice a month [ ] Other: If I'm not working, it's because: Previous employer's name: Previous employer's address: Previous job/occupation/profession/title: Date previous job began: Date previous job ended: Why I left previous job: Gross monthly pay at previous job: $ Total gross income from last three years' tax returns: Year $ Year $ Year $ My total gross income from January 1 of this year to the date of this Affidavit: $ Education/Training: School Name High School College Post-Graduate Occupational Training # of Years There Last Year There Degree Earned INCOME: Gross Monthly Income: What to list: 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. Monthly average: Use a monthly average for items that change from month to month. Monthly total for weekly or biweekly income: Multiply weekly income by 4.33 to get the monthly total. Multiply income received every other week by 2.165 to get the monthly total. Page 3 of 10 Revised July 2013 © 2013 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com Gross monthly salary/wages .................................................................................................. Rate of Pay: $ per [ ] hour [ ] week [ ] month [ ] year Expenses my employer pays for: Include all amounts your employer reimburses you for, including travel for work and to distant job sites, per diem, and living expenses for time spent at another job site. Automobile provision or allowance........................................................................... Auto expenses, such as gas, repairs, and insurance ................................................... Lodging ...................................................................................................................... Other (explain): Commissions/Bonuses ........................................................................................................... Tips ........................................................................................................................................ Self-employment income ....................................................................................................... Social Security benefits.......................................................................................................... Worker's compensation and/or disability income ................................................................. Unemployment compensation ............................................................................................... Gifts/Prizes ............................................................................................................................. Spousal support (alimony) payments from a previous marriage ........................................... Rental income (net after expenses) ........................................................................................ Contributions to household living expenses by others .......................................................... Other (explain): Include dividends, pensions, interest, trust income, annuities, etc. $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total Gro