Your Name: Your Address: Your City, State, Zip Code: Your Phone Number: ATLAS Number (if applicable) Attorney Bar Number (if applicable): Representing Self (Without Attorney) OR Petitioner OR Respondent Attorney for FOR CLERK’S USE ONLY IN THE SUPERIOR COURT OF THE STATE OF ARIZONA IN AND FOR THE COUNTY OF MARICOPA ) ) ) ) vs. (Person Ordered to Pay Support) Case #: ) ) Respondent. 1. OBLIGOR’S FINANCIAL AFFIDAVIT ) Petitioner, NAME: Last 2. First M.I. ADDRESS: Street Address City 3. TELEPHONE NUMBERS: Home: Work: ( 4. State ( ) ) Message: / DATE OF BIRTH: Month Zip Code ( ) / Day Year 5. NAME OF PRESENT SPOUSE: 6. NAME AND AGE(S) OF MINOR CHILD(REN), COMMON TO YOU AND YOUR PRESENT SPOUSE OR PREVIOUS RELATIONSHIP, LIVING WITH YOU: NAME ©Superior Court of Arizona in Maricopa County June 25, 2007 ALL RIGHTS RESERVED AGE NAME AGE DRESE13f Page 1 of 4 USE CURRENT VERSION American LegalNet, Inc. www.FormsWorkflow.com Case No. 7. NAME OF EMPLOYER: ADDRESS OF EMPLOYER: Street Address City 8. State Zip Code IF UNEMPLOYED NOW, WHY? YOUR USUAL OCCUPATION? WHEN LAST EMPLOYED: 9. LIST ALL INCOME YOU RECEIVE FROM ANY SOURCE: INCOME DOLLAR AMOUNT Gross monthly pay (wages, salary, tips, commission, etc.) Rents (amount after expenses deducted) Pensions and retirement income Social Security income Dividends and interest income Disability and unemployment pay Current child support and spousal maintenance received Welfare and Aid to Dependent Children Trust funds Income from any other source $ $ $ $ $ $ $ $ $ $ TOTAL MONTHLY INCOME $ 10. LIST ALL BANKS, SAVINGS AND LOAN, CREDIT UNIONS, OR OTHER FINANCIAL INSTITUTIONS IN WHICH YOU HOLD ACCOUNTS AND/OR SHARES: INSTITUTION DOLLAR AMOUNT ADDRESS $ $ $ ©Superior Court of Arizona in Maricopa County June 25, 2007 ALL RIGHTS RESERVED DRESE13f Page 2 of 4 USE CURRENT VERSION American LegalNet, Inc. www.FormsWorkflow.com Case No. ____________________________ INSTITUTION ADDRESS DOLLAR AMOUNT $ $ $ 11. LIST THE NAMES OF ANY INDIVIDUALS OTHER THAN THOSE NAMED IN THE PRESENT ACTION, WHOM YOU ARE UNDER COURT ORDER TO SUPPORT, AS WELL AS THE AMOUNT OF THE ORDER: AMT. OF ORDER NAME $ $ $ $ $ 12. LIST ALL PROPERTY, INCLUDING YOUR HOME AND ALL MOTOR VEHICLES, ITS VALUE ANY LIENS OR INDEBTEDNESS, AND WHO INDEBTEDNESS IS OWED: DESCRIPTION OF PROPERTY VALUE INDEBTEDNESS OF LIEN $ $ $ $ $ $ $ TO WHOM OWED $ ©Superior Court of Arizona in Maricopa County June 25, 2007 ALL RIGHTS RESERVED DRESE13f Page 3 of 4 USE CURRENT VERSION American LegalNet, Inc. www.FormsWorkflow.com Case No. 13. LIST ALL MONTHLY EXPENSES WHICH YOU ARE RESPONSIBLE TO PAY AT THE PRESENT TIME: MORTGAGE/RENT $ GAS & ELECTRIC $ FOOD MEDICAL & DENTAL INSURANCE WATER $ TRANSPORTATION (Gas, Bus Fare, Not car payment) $_____________ $ TELEPHONE $ OTHER $______________________ $____________ 14. LIST ALL INSTALLMENT CONTRACTS AND REVOLVING CREDIT PAYMENTS THAT YOU HAVE NOT INCLUDED IN ITEM 14: TO WHOM OWED BALANCE DUE MONTHLY AMOUNT $ $ $ $ $ $ $ $ 15. $ $ TOTAL MONTHLY EXPENSES (TOTAL ITEMS 14 AND 15): $ OATH OR AFFIRMATION AND VERIFICATION I swear or affirm that the information on this document is true and correct under penalty of perjury. Signature Date by Sworn to or Affirmed before me this: (date) My Commission Expires: Deputy Clerk or Notary Public ©Superior Court of Arizona in Maricopa County June 25, 2007 ALL RIGHTS RESERVED DRESE13f Page 4 of 4 USE CURRENT VERSION American LegalNet, Inc. www.FormsWorkflow.com