FINANCIAL DECLARATION - Traffic Petition Docket Number: ________________ Full Name: __________________________________________ Age: ________ Date of Birth: ___________________ Address: ________________________________________________________ Telephone: _____________________ Street City Marital Status: Single ______ Married ______ Divorced ______ Separated ______ Widowed ______ Name of wife/husband: ___________________________________ Children: Number ______ Ages ___________ Social Security Number: _________________________________ Driver's License No. _______________________ EMPLOYMENT RECORD SPOUSE EMPLOYMENT Employer: Address: City: Type of Job: Gross Salary: Take Home: _______________________________ _______________________________ _______________________________ _______________________________ $__________________ (Week/Month) $__________________ (Week/Month) OTHER INCOME Employer: Address: City: Type of Job: Gross Salary: Take Home: _______________________________ _______________________________ ___________________________ _______________________________ $__________________ (Week/Month) $__________________ (Week/Month) LIST YOUR MONTHLY EXPENSES Unemployment & Disability Social Security Welfare, AFDC Veterans Benefits Workers Compensation Child Support Payments Support from parents All Other Income $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ Rent or House Payment Car Payments Medical Payments Loan Payments Clothing & laundry Food Other Payments $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ $ ________________ WHO DO YOU OWE? WHAT DO YOU OWN? LIST VALUE Name Monthly Payment Balance Owed Cash House: $ _______________________ $ _______________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Cars & Other Vehicles $ _______________________ Life Insurance Bank Accounts Name of Bank $ _______________________ $ _______________________ Branch ____________________________________________ I declare under penalty of perjury that the foregoing Financial Declaration is true and correct and if sworn as a witness, I could testify competently thereto. Executed at ____________________, this ______ day of _____________, 200___ . ___________________________________________ Signature of Petitioner Local form TR01a (0511) American LegalNet, Inc. www.USCourtForms.com